V2 - PLANETS of ORTHODONTICS - Volume II - Diagnosis and Treatment Planning

PLANETS OF
ORTHODONTICS
Volume 2
Diagnosis and Treatment Planing
Authors:
Dr. Mohammed Almuzian

Specialist Orthodontist (UK)
BDS Hons (UoM), MDS Ortho. (Distinction), MSc.HCA (USA), Doctorate Clin.Dent. Ortho. (Glasgow), Cert.SR
Health (Portsmouth), PGCert.Med.Ed (Dundee), MFDRCSIre., MFDSRCSEd., MFDTRCSEd., MOrth.RCSEd.,
FDSRCSEd., MRACDS.Ortho. (Australia)
Dr. Haris Khan

Consultant Orthodontist (Pakistan)
Professor in Orthodontics (CMH Lahore Medical College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), FFDRCS Ortho. (Ire.)
With
Dr. Ali Raza Jaffery

Specialist Orthodontist (Pakistan)
Associate Professor Orthodontics (Akhtar Saeed Medical and Dental College)
BDS (Pakistan), FCPS Orthodontics (Pakistan), MOrth.RCS (Edin.)
Dr. Farooq Ahmed

Consultant Orthodontist (UK)
BDS. Hons. (Manc.), MDPH (Manc.), MSc (Manc.), MFDS (RCS Ed.), PGCAP, MOrth.RCS (Eng.), FDSRCS Ortho.
(Eng.), FHEA
Contributors
Dr. Samer Mheissen/ Specialist Orthodontist (Syria)

Dr. Mark Wertheimer/ Consultant Orthodontist (South Africa)
Dr. Mushriq Abid/ Specialist Orthodontist and Professor in Orthodontics (Iraq/ UK)
Dr. Emad E Alzoubi/ Specialist Orthodontist and Lecturer of Orthodontics (Malta)
Dr. Dalia El-Bokle/ Specialist Orthodontist and Professor in Orthodontics (Egypt)
Dr Rim Fathalla/ Specialist Orthodontist (Egypt)
Dr. Lubna Almuzian/ Specialist Paediatric Dentist (UK)
Dr. Ahmed El-Shanawany/ Specialist Orthodontist (Egypt/ UK)
Dr. Lina Sholi/ Specialist Orthodontist (KSA/ Turkey)
Dr. Ahmed M. A. Mohamed/ Specialist Orthodontist (Jordan/ UK)
Dr. Syed A. A. Bukhari/ Specialist Orthodontist (India/ KSA)
Dr. Muhammad Q. Saeed/ Professor in Orthodontics (Pakistan)
Dr. Asma R. Chaudhry/ Assistant Professor in Orthodontics (Pakistan)
Dr. Taimoor Khan/ Specialist Orthodontist (Pakistan)
Dr. Maham Munir/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Eesha Najam/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Abbas Naseem/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Amna S. Noor/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Hafiz M. Z. Majeed/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Hassan Saeed/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Maham Batool/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Eesha Muneeb/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Awrisha Tariq/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Hajira Arham/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Ayesha Tariq/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Farhana Umer/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Aroosh Ahmed/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Maha Arooj/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Khaula Ashfaq/ Postgraduate Trainee in Orthodontics (Pakistan)
Dr. Ayesha Iqbal/ House Officer/ CMH IOD LMC (Pakistan)
Acknowledgments
This book is the sum and distillate of work that would not have been possible without the support of our families
and friends. Special thanks to the contributors who continuously provided advice in developing this book and
up-dating individual chapters.
Finally, we acknowledge the hard work and expertise of Ms Faiza Umer Hayat who was responsible for compiling
this volume.
Copyrights
All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or
by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior
written permission of Dr Mohammed Almuzian and Dr Haris Khan who have the exclusive copyright, except in
the case of brief quotations embodied in critical reviews and certain other non-commercial uses permitted by
copyright law. For permission requests, contact them at [email protected]
ISBN-13 : 979-8428271911
ASIN : B09TYM7D4Z
Preface
Questions expose our uncertainty, and uncertainty has been our motive. The authors and contributors have ag-
gregated this book, and the series of books to follow, in answer to questions covering the breadth and depths of
orthodontics. This volume covers an orthodontic examination, anchorage, space planning and variants of maloc-
clusions including sagittal, transverse, vertical and local problems. Befittingly the theme of this chapter is Mars
to represent the importance of this volume.
The writing of the book started with the amalgamation of orthodontic notes and the experience of the main two
authors, Dr Mohammed Almuzian and Dr Haris Khan. The other authors helped in proofreading, summarising
the key points in a form of the ‘exam night re-view’. There have been numerous contributors to this book, as
co-writers of specific chapters or as proofreaders, we seek to acknowledge them. To give credit where it is due,
the role of the authors and contributors of this volume are listed on the title page of each individual chapter.
Table of Contents Pitchfork analysis...................................................................19
Pancherz analysis...................................................................19
Bolton template analysis.......................................................19
Facial, smile and dental analysis.......................... 1 3D cephalometric superimpositions ..................................19
Computed tomography (C.T.)..............................................19
Facial analysis (macro-aesthetics) ...................................2 Frontal cephalometry/ posteroanterior radiographs.........21
Are CFA parameters standard?............................................2 Hand or wrist radiographs....................................................21
Importance of CFA................................................................2 Radionuclide imaging...........................................................21
Methods of CFA.....................................................................2 Requirement of digital photography ..................................21
Steps in CFA...........................................................................3 Intraoral scanning (oral scanner) ......................................22
Frontal facial analysis............................................................3 Types of intraoral imaging techniques................................22
Transverse analysis from frontal view.................................4 3D digital study models........................................................23
Aetiologies of lip incompetency .........................................5 Stereophotogrammetry.........................................................23
Profile analysis........................................................................5 Laser scanning........................................................................23
2. Analysis of the high midface............................................5 Optical surface scanning.......................................................24
3. Analysis of the maxillary area..........................................5 Structured light imaging.......................................................24
5. Analysis of the mandibular area......................................6 Magnetic resonance imaging and orthodontics................24
Smile analysis (mini-aesthetics) and its components.......6 Cephalometric In Orthodontics.......................... 31
2. Gingival Heights, Shape and Contour ......................7 History.....................................................................................32
3. Connectors..........................................................................7 Equipments.............................................................................32
5. Tooth Shade and Color.....................................................7 Clinical stages in taking a cephalogram..............................32
Imaging In Orthodontics: Radiography & Uses of cephalometry ...........................................................32
Photography......................................................... 13 Requirements of cephalometric measurement..................33
Goals of imaging....................................................................14 Common cephalometric landmarks....................................33
Classification of imaging techniques .................................14 Cephalometric lines for skeletal analysis............................33
Radiographic imaging techniques ......................................14 Cephalometric lines for dental analysis..............................34
Key aspects of IRMER 2000..................................................14 Cephalometric measurements for profile analysis............34
X-Ray variables.......................................................................14 Cephalometric measurements for lip analysis...................34
Measurements of radiation doses ......................................14 Cephalometric measurement for labionasal analysis........35
Image receptors ....................................................................16 Cephalometric measurement for labio-mental analysis...35
Setting the chair-side dental X-ray equipment..................16 Cephalometric analysis techniques.....................................35
Occlusal radiographs.............................................................16 Key cephalometric analysis ..................................................35
Periapical radiographs...........................................................16 Mills’ Eastman correction (Mills, 1970)..............................38
Bitewing radiographs.............................................................16 Limitations of the Eastman correction ..............................38
Orthopanoramic radiography (OPG).................................16 Limitations of Steiner analysis.............................................39
Lateral cephalogram..............................................................17 Space Analysis In Orthodontics........................... 43
Types of errors in cephalometric analysis...........................18 Clinical application of space analysis..................................44
Projection error......................................................................18 Advantages and disadvantages of RLSA ............................46
Maxillary skeletal and dental changes.................................19 Other Methods for Space Analysis in Permanent
Mandibular skeletal and dental changes.............................19 Dentition.................................................................................46
Template analyses ..................................................................19 Symmetry of the Arch...........................................................47
Bolton analysis........................................................................47 Helkimo Clinical Dysfunction (HCD) Index....................65
Bolton ratios, malocclusion and gender ............................48 GOSLON index......................................................................65
Bolton ratios and ethnic groups...........................................48 Tooth Wear Index..................................................................65
Exam Night Review...............................................................48 Root resorption indices ........................................................65
Orthodontic Indices............................................. 51 Maxillary suture fusion index..............................................67
Ideal characteristics of an index...........................................52 Mid-palatal suture density ratio (MSDR) ..........................67
Types of indices......................................................................52 Five stage midpalatal suture maturation method..............67
Other criteria of the DHC.....................................................56 EXAM NIGHT REVIEW.....................................................67
Aesthetic Component (AC)..................................................56 Orthodontic Anchorage....................................... 71

Index of Orthognathic Functional Treatment Need Intra-oral sources of OA.......................................................72
(IOFTN)..................................................................................56 Extra-oral sources of OA......................................................72
Advantages and disadvantages of the IOTN......................56 Terms and principles used with OA....................................72
Peer Assessment Rating (PAR).............................................57 Classification of OA...............................................................72
Anterior segments ...............................................................57 Supplementing the OA unit..................................................73
.................................................................................................58 OA in three planes.................................................................74
Buccal occlusion.....................................................................59 Assessment of OA need.........................................................74
Table 11: Buccal occlusion assessment ...............................59 EXAM NIGHT REVIEW.....................................................75
Overjet.....................................................................................59 TEMPORARY ANCHORAGE DEVICES ........... 79
Centerlines..............................................................................59 A brief history of TADs.........................................................80
Advantages of PAR index .....................................................60 Design features of TADs ...................................................80
Disadvantages of PAR index.................................................60 These include:.........................................................................80
Outcome assessment of PAR................................................60 Characteristics for ideal TADs.............................................80
Index Of Complexity Outcome & Need (ICON)..............60 These include:.........................................................................80
Table 16: Interpretation of ICON scores.............................60 Osseointegrating screws........................................................80
American Board of Orthodontics Discrepancy Types of osseointegrating screws.........................................80
Index (ABO DI) ....................................................................61 These include:.........................................................................80
Crowding.................................................................................62 Mechanically retained screws...............................................81
Buccal Occlusion....................................................................62 Types of mechanically retained screws...............................81
Cephalometric analysis.........................................................63 Stability & failure of mini-screws.........................................82
Advantages of ABO DI..........................................................63 Factors affecting failure of miniscrews ...............................83
Disadvantages of ABO DI.....................................................63 The failure rate of miniscrews according to the site
Handicapping malocclusion assessment record ...............63 of insertion .............................................................................83
Little irregularity (LI) index.................................................63 Special features in the miniscrews.......................................83
Crowding index ....................................................................63 How to optimise the success rate of miniscrews?..............84
Maxillary expansion indices ................................................64 Post-operative instructions...................................................84
Treatment difficulty index for unerupted maxillary Direct Vs indirect anchorage ...............................................84
canines ....................................................................................64 Bicortical anchorage..............................................................85
Plaque index ..........................................................................64 Complications associated with TADs..................................85
Calculation of plaque index .................................................64 Exam night review.................................................................85
Gingival index (GI)................................................................64 Extraction in orthodontics .................................. 91
Basic Periodontal Examination (BPE)................................64
Why do we take teeth out?....................................................92 Intra-oral features of Class I malocclusion.........................110
Claimed advantages of the non-extraction approach ....92 Methods of space provision to treat Class I
Claimed advantages of extraction approach ...................92 malocclusion...........................................................................110
Prevalence of extractions in orthodontics..........................92 Exam night review.................................................................110
Evidence about the detrimental effects of extraction........92 Bimaxillary Proclination...................................... 113
Extraction of Specific teeth...................................................93 Aetiologies of bimaxillary proclination..............................114
Extraction of primary teeth..................................................93 Classification of bimaxillary proclination..........................114
Guidelines for extraction of primary teeth.........................94 Features of bimaxillary proclination...................................114
Extraction of permanent teeth.............................................94 Treatment of bimaxillary proclination................................115
Contraindications for lower incisor extraction..................94 Treatment considerations while managing bimaxillary
Problems associated with lower incisor extractions..........94 proclination............................................................................115
2. Lower canine extraction....................................................95 Relapse after treating bimaxillary dentoalveolar
3. Lower first premolars extraction......................................95 proclination............................................................................115
4. Lower second premolars extraction................................95 Exam night review.................................................................115
5. Lower first molar extraction.............................................95 Class II Division 1 Malocclusion ........................ 119
Contraindications for first molar extraction......................95 Incidence of Class II Division 1 malocclusion ..................120
6. Lower second molar extraction.......................................95 Aetiology of Class II Division 1 malocclusion...................120
Contraindications for second molar extraction.................96 Features of Class II Division 1 malocclusion ....................120
Advantages of second molar extraction..............................96 Type of lip behaviour to achieve anterior oral seal in
7. Upper central incisor extraction......................................96 patients with Class II malocclusion.....................................121
8. Upper lateral incisor extraction.......................................96 Justifications for early treatment of Class II
Contraindications for for upper lateral incisor malocclusions .....................................................................121
extraction................................................................................96 Treatment timing for Class II Division 1 malocclusion....121
9. Upper canine extraction...................................................96 Growth modification / functional jaw orthopaedics
10. Upper first premolars extraction...................................96 to treat Class II Division 1 malocclusion............................121
11. Upper second premolar extraction................................97 Effects of Class II functional appliances.............................121
12. Upper first molar extraction...........................................97 The proposed advantages of the phase I intervention ......121
13. Upper second molar extraction.....................................97 Disadvantages of phase I intervention ..............................122
Third molars extraction........................................................97 Effectiveness of phase I intervention .................................122
EXAM NIGHT REVIEW.....................................................98 Orthodontics camouflage to treat Class II Division 1 maloc-
Interproximal Enamel Reduction ....................... 103 clusion.....................................................................................122
Indications of IPR..................................................................104 Orthodontics camouflage treatment modalities to treat
General advice before commencing IPR procedure ........104 Class II Division 1 malocclusion..........................................122
Methods of IPR .....................................................................104 Favourable features for orthodontics camouflage.............122
Air rotor stripping (ARS)......................................................105 Combined orthodontic-surgical approach.........................122
Long term potential side effects of IPR...............................105 Indicators for orthognathic surgery....................................122
Exam night review.................................................................105 Aetiology of relapse of the treated Class II Division 1
Interproximal Enamel Reduction........................................105 malocclusion..........................................................................123

Enhancing the stability of treated Class II Division 1
CLASS 1 MALOCCLUSION................................ 109
malocclusions........................................................................123
Aetiologies of Class I malocclusion.....................................110
Exam night review.................................................................123
Extra-oral features of Class I malocclusion........................110
Class II Division 2 malocclusion ........................ 127 Types of maxillary skeletal deficiency.................................142
Classification of Class II Division 2 malocclusion ............128 Benefits of treating displacement ........................................142
Incidence of Class II Division 2 malocclusion...................128 Incidence of transverse maxillary deficiency.....................143
Aetiology of Class II Division 2 malocclusion...................128 Age-related changes in maxillary dimension.....................143
Features of Class II Division 2 incisor relationships.........128 Aetiologies of transverse maxillary deficiency...................143
Justification for treatment.....................................................129 Clinical features of transverse maxillary deficiency..........143
Treatment aims.......................................................................129 Diagnosis of transverse maxillary deficiency.....................143
Treatment options..................................................................129 CBCT evaluation....................................................................144
Timing of treatment..............................................................129 Treatment objectives .............................................................144
Stability and retention...........................................................130 How much expansion is required? .....................................144
Proclination of lower incisors in Class II Division 2 Non-surgical maxillary expansion ......................................144
cases.........................................................................................130 Advantages of Quadhelix appliance....................................145
Long-term retention plans ...................................................130 Disadvantages of Quadhelix appliance...............................145
Exam night review.................................................................130 Principle of RME....................................................................145
Class III Malocclusion.......................................... 133 The rationale for expansion treatment................................145
Classification of Class III malocclusion..............................134 Types of conventional RME..................................................146
Classification Class III malocclusion based on the The influence of the height of RME ....................................146
severity ....................................................................................134 Proposed indications of the RME........................................146
Prevalence of Class III malocclusion...................................134 Contraindications and limitations of conventional
Aetiologies of Class III malocclusion..................................134 RME.........................................................................................147
Clinical features of Class III malocclusion.........................134 Potential complications of RME..........................................147
Treatment options for Class III malocclusion....................135 Mid-palatal suture assessment methods.............................147
Interceptive treatment...........................................................135 Mid-palatal suture maturation classification .....................147
Growth Modification.............................................................136 Interpretation mid-palatal suture maturation classification:

147
1. Protraction Facemask (PFM).........................................136
Mid-palatal suture density ratio ..........................................148
2. Chin cup therapy.............................................................136
Protocols of maxillary expansion .......................................148
3. The Frankel III (FR-3) appliance...................................136
Surgical maxillary expansion...............................................149
4. Bone anchored maxillary protraction/Bollard
1. Surgically assisted RME (SARME or SARPE).............149
plates (BAMP).......................................................................136
Indications for SARPE ..........................................................149
Orthodontic camouflage treatment.....................................136
Complications during SARPE..............................................149
Favourable features for orthodontic camouflage .............137
2. Multiple piece maxillary osteotomy (MPMO) ............149
Guidelines for orthodontic camouflage..............................137
Retention and stability secondary to MPMO....................149
Consideration of a single lower incisor extraction............137
Factors & Yardsticks ............................................................150
Bracket prescription can aid camouflage of the
Appliances for unilateral maxillary expansion..................150
Class III malocclusion...........................................................137
Treatment of scissor bite.......................................................150
Dental decompensation and orthognathic surgery...........137
Stability and retention of expansion....................................150
Anterior crossbites.................................................................150
Transverse arch discrepancY................................ 141 Requirement for the successful results using URA...........150
Different terminologies in transverse maxillary
deficiency ...............................................................................142
Dental & Skeletal Asymmetries........................... 157
Prevalence of dental & skeletal asymmetries ....................158 habit.........................................................................................178
Aetiology of dental & skeletal asymmetries.......................158 Management of digit-sucking habits .................................179
Classification of dental & skeletal asymmetries.................158 Types of removable habit breakers .....................................179
Overview of different types of asymmetry ........................158 Types of fixed habit breakers .............................................179
Traumatic asymmetry...........................................................159 Summary of evidence ..........................................................179
Hemifacial microsomia (HFM)...........................................159 Management of mouth breathing........................................180
Clinical features of HFM.......................................................159 Management of secondary tongue thrust...........................180
Types of HFM.........................................................................159 Myofunctional therapy for the treatment of AOB.............180
Classification of HFM ..........................................................159 Combined myofunctional and extraoral appliance
Juvenile Rheumatoid Arthritis (JRA)..................................159 combination therapy.............................................................182
Treatment of Juvenile Rheumatoid Arthritis.....................160 Extraoral appliance for management of AOB....................182
Idiopathic condylar resorption (ICR) ...............................160 Treatment principles in the management of AOB
Torticollis (Wry Neck)...........................................................160 using fixed appliances............................................................183
Hemifacial hypertrophy........................................................160 Kim mechanics.......................................................................183
Hemifacial atrophy (Parry-Romberg syndrome)..............160 Modified Kim mechanics......................................................184
Asymmetric mandibular excess...........................................160 Molar intrusion using skeletal anchorage...........................184
Management of asymmetric mandibular excess................161 Treatment considerations of AOB treated with molar
Mandibular displacements on closure................................162 intrusion .................................................................................184
Dental asymmetries...............................................................162 Rapid molar intrusion device (RMI)...................................185
Causes of dental midline asymmetry..................................162 Advantages and disadvantages of RMI...............................185
Class II subdivision................................................................162 Repelling magnets for the treatment of OAB.....................185
Class III subdivisions.............................................................162 Orthognathic option for management of skeletal
Management of functional asymmetry...............................164 AOB.........................................................................................186
Management of skeletal asymmetry....................................164 Factors contributing to skeletal relapse .............................186
Exam night review.................................................................165 Adjunctive procedures..........................................................186
High Angle Cases................................................. 169 Stability of AOB treatment...................................................186
Aetiology of high angle cases...............................................170 Causes of relapse of treated AOB cases...............................187
Clinical features of high angle cases....................................170 Retention of treated AOB cases............................................187
Radiographical features.........................................................170 Methods for retention...........................................................187
Clinical implications in treating high angle.......................170 Difficulty associated with the treatment of AOB ..............188
Treatment considerations.....................................................170 Posterior open bite.................................................................188
Exam night review.................................................................171 Causes of posterior open bite...............................................188
Anterior open bite................................................ 173 Treatment of posterior open bite.........................................188
Aetiology of AOB...................................................................174 Exam night review................................................................188
Classification of AOB............................................................174 Deep bite .............................................................. 199

Incidence of AOB...................................................................174 Basic terminologies................................................................200
Predictors of skeletal open bite............................................175 Aetiology deep overbite.........................................................200
Features of skeletal open bite................................................175 Principles of deep incisor overbite reduction.....................200
Aetiology of AOB...................................................................176 Consideration factors for the method of treating DOB....200
Digit Sucking Habit...............................................................178 These include:.........................................................................200
Long term effects of pacifier and dummy sucking Management of overbite .....................................................201
Methods to reduce the unwanted labial tipping of lower Supernumerary Teeth .......................................... 228
incisors during levelling .....................................................201 Incidence of supernumerary teeth.......................................229
Advantages of segmental archwires technique ..................202 Aetiology of supernumerary teeth.......................................229
Disadvantages of segmental mechanics..............................202 Genetic influences in the development of
Effectiveness of different approaches...................................202 supernumerary teeth.............................................................229
Exam night review.................................................................203 Clinical features and effects of supernumerary teeth ......230
References.........................................................................................203 Classification of supernumerary teeth................................230
Low Angle Cases................................................... 206 Examination of supernumerary tooth................................230
Aetiology of low angle cases.................................................207 Management of supernumerary tooth................................231
Features of low angle cases...................................................207 Detailed management of each type of supernumerary ...231
Principals of treatment .........................................................207 Conical supernumerary ......................................................231
Methods to reduce overbite ................................................207 The effect of conical supernumerary on permanent
The Dahl concept...................................................................208 incisors are:............................................................................231
Exam night review.................................................................208 Tuberculate supernumerary.................................................231
Hypodontia........................................................... 210 Supplemental supernumerary teeth....................................232
Classification of hypodontia ................................................211 Odontomes supernumerary ................................................232
Candidate genes ....................................................................211 ..................................................................................................

232
Incidence of hypodontia ......................................................211
Evidence summary................................................................232
Aetiology and theories of hypodontia ................................212
Clinical presentation of hypodontia ...................................213
Impacted Maxillary Central Incisor.................... 236
Malocclusion features of hypodontia patients ..................213
Incidence of unerupted central incisor...............................237
Indications for treatment .....................................................213
Aetiology of unerupted central incisor...............................237
General treatment principles................................................213
Effects of unerupted central incisor.....................................237
Options for treatment ...........................................................214
Diagnosis of unerupted central incisor...............................237
These include (Gill and Barker, 2015):................................214
Considerations during treatment planning ......................238
Advantages of auto-transplantation (Aslan et al., 2010)...215
The correlation between dilacerated and impaction
Problems and solutions of cuspid substitution..................215
of incisors................................................................................238
Benefits of cuspid substitution.............................................215
Types of tooth dilacerations.................................................238
.................................................................................................217
Methods for space creation to allow spontaneous
Compensated axial tip of brackets for space closure
eruption..................................................................................238
treatment option...................................................................219
Extraction/removal of physical obstruction.......................239
Camouflaging the size and shape of teeth for space
Watchful waiting or mechanical traction?..........................239
closure treatment option.......................................................219
Closed surgical exposure techniques .................................239
E. Reopen or redistribute space.........................................219
Open versus closed exposure (eruption) techniques........240
Space opening and prosthetic replacement........................220
Surgical extraction of the impacted incisor and
Types of final restorations.....................................................220
coronectomy ..........................................................................240
Criteria for implant placement ...........................................220
Surgical extraction or auto-transplantation.......................240
Success of dental implants....................................................220
Advantages of autotransplantation......................................240
Treatment options for absent premolars.............................221
Risks and disadvantages of autotransplantation ...............240
Evidence summary................................................................221
Factors affecting the success of autotransplantation.........240
Success rate of autotransplantation ....................................240 Type of surgical exposure ....................................................254
Prognosis of autotransplantation ........................................241 Open exposure.......................................................................254
Management of ankylosed maxillary incisors....................241 Advantages of open exposure...............................................254
Exam night review.................................................................243 Disadvantages of open exposure..........................................254
Impacted Canine.................................................. 247 Closed surgical exposure......................................................254
Prevalence and Incidence.....................................................248 Advantages of closed exposure............................................255
Development and eruption of maxillary canines..............248 Disadvantages of closed exposure.......................................255
Aetiology of impacted canines.............................................248 Crescini’s tunnel technique ..................................................255
Recent classification of aetiology of maxillary canine Choices of surgical exposure................................................255
impaction...............................................................................248 Mechanical eruption of the impacted canine.....................256
These include (Becker and Chaushu, 2015):......................248 Indications for surgical removal of the palatally ectopic
Theories of palatally impacted canines...............................249 permanent canine..................................................................256
Classification of impacted maxillary canines ...................249 Indication of transalveolar autotransplant.........................257
These include:.........................................................................249 Indication of surgical repositioning ...................................257
Investigations and diagnosis ...............................................250 Causes of poor outcome ......................................................257
Magnification technique.......................................................250 Impacted mandibular canine...............................................257
Parallax Technique.................................................................250 Exam Night Review...............................................................258
Ericson and Kurol sectors’ classification as predictors of Primary Failure Of Eruptions.............................. 263
severity of impacted canine .................................................251 .............................................................................. 263
Four sector classification by Lindauer ...............................251 Classification of failure of eruption ....................................264
These include:.........................................................................251 Incidence of PFE....................................................................264
The three-sector classification by Dr Crescini...................251 Aetiology of PFE....................................................................264
Sector classification by Stivaros and Mandall ..................251 Features of PFE ......................................................................264
Alpha angle as predictors of severity of impacted canine.251 Treatment options of the PFEc.............................................264
β- and Gamma angle as predictors of severity of Aetiology of the mechanical failure of eruption ..............264
impacted canine.....................................................................251 Exam night review.................................................................265
Distance of the canine’s crown from the occlusal plane as Transposition of teeth ......................................... 267
predictors of severity of impacted canine...........................252 Types of transposition...........................................................268
Position of canine root apex anteroposteriorly as Aetiology of transposition....................................................268
predictors of severity of impacted canine...........................252 Prevalence of transposition..................................................268
Incidence of root resorption (RR) ......................................252 Classification .........................................................................268
Risk factors for resorption of lateral roots..........................252 Maxillary canine and the first premolar (Mx.C.P1) .........268
Management and treatment options for impacted Factors affecting treatment decision ..................................269
canines ...................................................................................252 These include: ........................................................................269
Indication for no active treatment.......................................253 Maxillary canine-lateral incisor transposition ..................269
Interceptive treatment...........................................................253 Maxillary canine-first molar transposition (Mx.C.M1)....269
Guidelines for interceptive extraction of deciduous Maxillary incisors transposition (Mx.I2.I1).......................269
canine......................................................................................253 Maxillary canine central incisor transposition..................269
b. Other interceptive techniques for impacted or Mandibular canine lateral incisor transposition ...............269
displayed canine ....................................................................253 Mandibular canine central incisor transposition .............269
Surgical exposure and orthodontic alignment...................254
Intraosseous migration.........................................................269
Aetiology of intraosseous migration .................................269
Clinical signs of intraosseous migration.............................269
Mupparapu classification for transmigrated mandibular ca-
nine..........................................................................................270
Third molar and its impaction............................. 273

Prevalence of third molar impaction and hypodontia......274
Aetiology of third molar impaction....................................274
Classification of third molar impaction..............................274
Lower incisor crowding and third molar debate...............274
Research recommendations .................................................274
1
Facial, smile and dental
analysis
Written by: Mohammed Almuzian, Haris Khan, Farhana Umer
In this Chapter
1. Facial analysis (macro-aesthetics) 16. Connectors
2. Are CFA parameters standard? 17. Embrasures: black triangles
3. Importance of CFA 18. Method to treat black triangle
4. Unattractive features of facial appearance 19. Tooth shade and color
5. Common landmarks used in facial anthropom- 20. Teeth size and space analysis
etry diagram needed 21. EXAM NIGHT REVIEW
6. Steps in CFA
7. Frontal facial analysis
8. Transverse analysis of the frontal view
9. Profile analysis
10. Analysis of the high midface
11. Analysis of the maxillary area
12. Analysis of the mandibular area
13. Smile analysis (mini-aesthetics)
14. Dental appearance (micro-aesthetics)
15. Gingival heights, shape and contour
Facial analysis (macro-aesthetics) as unattractive:
• Little show of vermilion border
Clinical facial analysis (CFA) is a method utilised by the cli-
nician to evaluate and judge the patient ‘s face; to define its • A very high or very low smile line
proportions, volume, appearance, symmetry, and visible de- • An upper lip that slopes backward
formities (Meneghini and Biondi, 2012). Facial aesthetics is
• An everted lower lip
considered a term used to describe the quality of beauty and
acceptance. • Extreme bilabial protrusion
Are CFA parameters standard? • Lack of a well-defined labiomental fold
One of the aims of CFA is to assess the facial aesthetics of the • Severe convex or concave profile
patient. There are many factors that affect the values during
To whom CFA might be beneficial?
CFA steps, which include:
These include:
• Racial background.
• Restorative dentist.
• Cultural difference.
• Maxillofacial surgeons.
• Gender.
• Orthodontists.
• Personal preference.
• Plastic surgeons.
• Clinician philosophy.
• Ophthalmic surgeons.
Importance of CFA
• ENT surgeon.
McLaughlin and Arnett (Arnett, 2004) in their textbook ‘’Fa-
cial and Dental Planning for Orthodontist & Oral Surgeon’’ • Rehabilitative dentists.
classify the dentofacial deformities in the adult patient into
• Dermatologists.
3 groups (G):
• Non-medical professionals such as hairdressers, eye-
• G1 which can be addressed comprehensively by routine
glasses designers and make-up artists.
orthodontic treatment
When should CFA be performed?
• G2 represents a deformity with mild to moderate skel-
etal discrepancies but can be well treated by some dental Initial CFA usually starts during the observation stage, from
compensation to achieve camouflage results the time of patient entrance to the clinical practice. It can also
be performed during the questionnaire stage. The clinician
• G3 represents cases with severe facial imbalance and
should have the skill of interpreting and understanding body
malocclusion, which should be treated by combined sur-
language. However, comprehensive CFA is usually undertak-
gery and orthodontics.
en during clinical examination stage (Meneghini and Biondi,
It is inappropriate to provide the treatment modalities of G3 2012)
to G2 without making a comprehensive facial diagnosis. So,
Methods of CFA
differentiation between these two groups is considered one of
the main criteria for treatment success. The way of differenti- These include:
ating between the two groups mainly depends on the evalua- • Direct clinical examination
tion and assessment of the diagnostic records; among these is
the clinical facial analysis (CFA). • Non-radiographical imaging methods (Clinical photo-
graphs).
To sum up, the main objectives of CFA are:
• 3D photography
• To diagnose and classify the deformities especially for
borderline cases. Common Landmarks used in Facial Anthropometry
• To plan the treatment approach that addresses the pa- These include:
tient concerns and complaints. • Alar curvature (Ac): The most lateral point on the
• To predict the treatment outcomes & prognosis. curved base line of each ala, indicating the facial inser-
tion of the nasal wingbase.
Unattractive facial features
• Cheilion (Ch): The point located at each labial commis-
The following features of facial appearance are generally rated sure.
2 Facial, Smile And Dental Analysis

• Crista philtre (Cphi): The peak of Cupid’s bow of the gren, 1971). NHP has 2° reproducibility (Cooke and Wei,
upper lip inferior. 1988, Lundström and Lundström, 1992).
• Endocanthion (Enc): The point at the inner commissure 2. Teeth should be in centric relation with first tooth con-
of the eye fissure, located lateral to the bony landmark. tact. Sometimes the use of a precentric wax bite is es-
sential when there is more than 1mm difference between
• Exocanthion (Excellence): The point at the outer com-
the retruded contact position (RCP) and the intercuspal
missure of the eye fissure, located slightly medial to bony
position (ICP). If the wax bite cannot be obtained with
exocanthion.
the condyle in the RCP due to adaptive changes, it is rec-
• Inferior Labrale Superius (ILs): A landmark on the up- ommended to use a deprogramming splint (Arnett and
per lip located midway between Labrale Superius and Gunson, 2004, Arnett, 2004).
Stomion Superius.
3. Lips should be in a relaxed position especially in case of
• Labrale inferius (Li): A point indicating the muco-cuta- vertical deficiency that resulted in soft tissue deformity
neous border of the lower lip. in centric occlusion.
• Labrale superius (Ls): A point indicating the muco-cu- 4. Undertaking a stepwise CFA in three planes of space.
taneous junction of the upper lip and philtrum. Frontal and profile analysis, this should not be under
emphasized since the major concerns of the patient are
• Soft tissue Nasion (N): The point in the midline of both
those that are visible viewed from the frontal aspect.
the nasal root and the nasofrontal suture, always above
45-degree analysis is recommended to deeply investigate
the line that connects the two inner canthi, identical to
some features that cannot be fully assessed by frontal and
bony nasion.
profile view. Other views for CFA including face base
• Soft tissue Pogonion (Pog): The most anterior midpoint (bird eye view), face down or worm view (submental),
of the chin, located on the skin surface in front of the nasal base view (subnasal).
identical bony landmark of the mandible.
Frontal facial analysis
• Pronasale (Prn): The most protruded point of the apex
A. Facial type analysis from frontal view
nose identified in lateral view of the rest position of the
head. Facial type represents the ratio between the facial height
(Trichion-Menton or Tr-Me) and width (Zygion-Zygion or
• Soft tissue A point: The deepest midline point on the
Zy-Zy)= (Facial index). The bizygomatic facial width is mea-
upper lip, which is located usually halfway between Sn
sured from the most lateral point of the soft tissue overlying
and Ls.
each zygomatic arch (zygion), and is approximately 70% of
• Soft tissue B point: The deepest midline point on the vertical facial height. Bitemporal width is measured from the
labiomental fold, which determines the lower border of most lateral point on each side of the forehead, and is 60 %
the lower lip or the upper border of the chin. of vertical facial height. While the bigonial width is measured
• Subnasale (Sn): The midpoint of the angle at the colu- from the soft tissue overlying the most lateral point of each
mella base where the lower border of the nasal septum mandibular angle (soft tissue gonion), and is usually 50% of
and surface of the upper lip meet. vertical facial height.
• Subtragion (Sbtr): The most anterior inferior point on There are three facial types, long, short and square face. The
the anterior inferior margin of the helix attachment to proportionate facial height to width ratio is 1.35:1 for males
the face, just above the earlobe. It is different from Porion and 1.3:1 for females (Naini and Gill, 2008).
• Superior Labrale Inferius (SLi): A landmark on the B. Vertical facial heights analysis from frontal view
lower lip located midway between Stomion Inferius and It is important to consider the vertical facial proportions and
Labrale Inferius. their balance in relation to the patient’s general build and
Steps in CFA personality. Ricketts (Ricketts, 1979) divided the face using
the middle and lower facial heights only. While Bell and Fish
These include: (Bell, 1980, Fish and Epker, 1980) divided the face into three
1. Positioning the patient in a Natural Head Position facial thirds (62-75 mm each) as below:
(NHP). NHP was developed by Moorrees (MOORREES, • Upper third, from hairline (trichion) to glabella or
1958). It is performed by asking the patient to walk into mid-brow.
the room for a few minutes to relax, then looking at a
mirror located at a distance 5 feet away, shake the head • Middle third, from glabella to subnasale,
until a comfortable position is achieved (Solow and Tall- • Lower third, from subnasale to soft tissue menton.
Facial, Smile And Dental Analysis 3

Facial thirds should be equal to each other, however, the in asymmetrical faces as patients with a marked
underlying cephalometric proportions of the middle to the occlusal cant habitually tilt the head to level the lip
lower facial height are not equal (45:55). This is because the line giving the impression of orbital dystopia. This
N, ANS, and Me points in cephalometrics are used instead of is usually corrected by bimaxillary leveling of the
Glabella, soft tissue Nasion, and soft tissue Menton used in occlusal plane.
soft tissue analysis.
• Rule of fifths in which each fifth is approximately
The lower anterior facial third is further subdivided the width of an eye, the mouth width is equal to the
into (Farkas et al., 1985): distance between the medial iris margins (65mm)
while the alar base width is equal to the intercanthal
• Upper lip segment from subnasale to stomodi-
distance (34mm).
on superioris which is 19-22mm on average, higher
in male than female and decreases with aging. B. Skeletal base assessment which includes:
• Lower lip and chin segment from stomodion • Mandibular assessment using chin-jaw imaginary
inferioris to soft tissue Menton which is 42-48mm line which is a line under the surface of the chin
on average. The height of this segment increases at maximum tissue contact. This imaginary line
with age due to submental fat accumulation. Lower should be parallel to the inter-pupillary line in the
lip and chin segment can be subdivided equally into absence of vertical orbital dystopia, otherwise, it is
the lower lip region, from stomodion inferioris to described as cant.
soft tissue B point, and the chin region, from soft
• Mid-face and maxillary assessment to detect signs
tissue B point to soft tissue soft tissue Menton.
of midface deficiency such as increased sclera show
• Interlabial gap that extends from stomodion above the lower eyelid, Class III problem, paranasal
inferioris to stomodion superioris. On average, hollowing, flattened upper lip, an obtuse nasolabial
it is 1-5mm and it is larger in females than males angle, narrow upper arch with crossbite and crowd-
because males have a longer upper lip. ing and wide buccal corridor.
Vertical maxillary excess (VME) C. Lip assessment which should be undertaken in the order
of the LAMP acronym (LAMP= Line, Activity, Morphol-
The main features are:
ogy, and Position of the lips).
• VME is asscoiated with and increase in the anterior low-
i) Lip lines: Vertically, the lower lip should cover the
er facial height.
incisal third of maxillary incisors, while the upper
• VME results from excessive inferior development of the lip should cover the upper two thirds. Maxillary
maxilla. incisor exposure at rest ranges from 2–4 mm, and it
depends on:
• VME is often accompanied by excessive gingival display
at rest and on smiling, referred to as a ‘gummy smile’. • Age.
• VME can be accompanied by an increased vertical chin • Lip activity during facial animation.
length, increased AFH and posterior mandibular rota-
• Upper lip length.
tion secondary to over eruption of the posterior teeth.
• Clinical crown length.
3. Transverse analysis from frontal view
• Anterior maxillary alveolar height.
These include:
• Maxillary incisor inclination.
A. Facial symmetry assessment cab be performed using:
• Combinations of the above.
• Facial midline which is represented by a perpen-
dicular line from glabella to the interpupillary If the upper lip length is very short, then, the patient would
line or to true horizontal line if the pupils are not be expected to show more of the upper incisors. Any attempt
leveled. Alternatively, the middle of the philtrum to reduce the incisor exposure in relation to a short upper lip
of the upper lip (Cupid’s bow) and glabella (Naini will lead to an unaesthetic reduced middle face height. Simi-
and Gill, 2008) or center of the nasal bridge (Arnett, larly, with a long upper lip, the patient would be expected to
2004) are used to construct the facial midline. If the show less or no upper incisor, both at rest and during facial
nasal deviation is significant, the philtrum might be animation.
deviated, and the use of vertical perpendicular from
ii) Lip activity: A strap-like lower lip often retroclines
glabella might be used as an alternative (Sheen and
incisors and commonly presents in Class II division
Sheen, 1987). Postural camouflage can be a problem

2 malocclusions (Moss, 1975). Flaccid lips are less 1. Total soft tissue profile analysis
likely to alter position with anteroposterior dental
This can be undertaken using:
movement significantly.
• Soft tissue nasion to Frankfurt horizontal: An easy
iii) Lip morphology: Vermilion show is normally
assessment of the relative protrusion of the mid third
12mm and 9mm for lower and upper lip respec-
and mandible can be made by assessing their position
tively (Fish and Epker, 1980). The position of full
relative to a perpendicular to the Frankfort plane pass-
lips are less likely to be altered significantly with the
ing downwards through soft tissue Nasion. With normal
anteroposterior dental movement while thin lips are
facial proportions, the soft tissue profile of the maxilla
more likely to ‘flatten’ with incisor retraction.
should be approximately 2-3 mm in front, and the soft
iv) Lip posture: Lip competency plays a role in the aeti- tissue pogonion should lie 2 mm behind this facial plane.
ology of malocclusion and treatment stability. Types However, the face can vary with ethnic norms, giving an-
of lip relationships are: terognathic, mesognathic or posterognathic profiles.
• Competent represents lips that are held to- • Angle of convexity (facial convexity) or profile angle:
gether at rest. Total facial angle is made by Glabella-subnasale-pog
(Burstone, 1958, Burstone, 1967). Class I occlusion cases
• Habitually competent in which the lips are
are usually present with a total facial angle that ranges
held apart at rest by more than 3–4 mm, but the
from 165-175 degrees, in comparison to a lower angle
patient tries to posture his/her jaw forward to
(less than 165 degrees) in Class II cases and higher value
achieve anterior lip seal like in Class II division
(higher than 175 degrees) in Class III cases (Arnett and
1 cases.
Bergman, 1993a, Arnett and Bergman, 1993b).
• Potentially competent in which the lips are
• Powell analysis (Powell and Humphreys, 1984): This
unable to be held together due to increased in-
analysis is made up of nasofrontal angle 160°, nasofacial
ter-labial space. The patient exerts muscle effort
angle 40°, and nasomental angle 160°.
to close them, which can be seen in the form of
an active mentalis muscle. The features of this • Steiner-Kole technique: It is used to determine the
condition are puckering of the chin area and dentofacial complex’s convexity by using SN-MP angle
flattening of the labiomental angle (LMA). which is 32°. In this analysis, the face can be classified
into divergent, convergent or normal. It is important
• Rolled blind upper lip means that the up-
note that the cranial base orientation may vary and be
per lip significantly retracts superiorly on smil-
steeper in some instances.
ing resulting in increased gingival show.
2. Analysis of the high midface
Aetiologies of lip incompetency
• Soft tissue glabella should be 2mm ahead of the soft tis-
These include:
sue nasion
• With aging, the lip incompetency is reduced.
• Orbital rim should be 2mm posterior to the eye globe
• Reduced lip legnth. (Fish and Epker, 1980).
• Increased lower anterior face height (LAFH) due to • Cheek bone contour should be smoothly convex from
VME. the eye’s outer canthus through the sub-pupil area to end
in the alar base (Fish and Epker, 1980).
• Increased LAFH due to posterior growth rotation.
• Morphology of the ears: If the external auditory meati
• Over-eruption of the buccal segments.
lie at unequal levels, this creates an asymmetrical facial
• Anteroposterior skeletal malrelationships. artifact.
• Proclined upper labial segment or lower labial segment 3. Analysis of the maxillary area
(LLS).
These include:
• Nasal base assessment which can be undertaken using
D. Smile analysis (see section smile analysis/ mini-aesthet- vertical line from soft tissue Nasion perpendicular to
ics) Frankfort horizontal (Zero Meridian line) or maxillary
Profile analysis plane (or ideally true horizontal line) with the patient in
NHP. Subnasale should be on this line (González-Ulloa

and Stevens, 1968). • Lower lip to chin relationship is assessed using Labiomen-
tal angle (LMA) which is formed between the lower lip
• Nasal projection represents the distance from tip of the
and chin. The average value of this angle is 110°–130°.
nose to true vertical line (TVL). This distance is usually
LMA depends on thickness of lower lip, mental fat area,
22m.
prominence of the chin itself, AP skeletal relationship,
• AP lip position that can be assessed using: lower incisor inclination, anterior lower face height -and
lower lip to upper incisor relationship.
i) TVL: The upper lip normally touches the TVL
described by Arnett (Arnett et al., 1999). 5. Anteroposterior chin position
ii) Esthetic line (E-line): E-line joins the nasal tip This can be undertaken using:
to soft tissue Pogonion. The upper lip should be 4
• Bass aesthetic analysis (Bass, 2003): This
mm behind this line in adults and it is very depen-
analysis uses Subnasale rather than soft tissue Na-
dent on nasal and chin projection (Ricketts, 1979).
sion from which a perpendicular is dropped to the
iii) Steiner line (S-line): S-line joins soft tissue true horizontal line with the patient in NHP. This
pogonion to the midpoint (columella) between analysis is useful for planning treatment in man-
Subnasale and nasal tip (pronasale). The lips should dibular retrognathia, where the maxillary position
touch this line. is correct.
iv) Harmony line (H-lines): H-lines was intro- • Zero Meridian line: Vertical from soft tis-
duced by Holdaway. The H-angle is formed by a line sue Nasion, perpendicular to the true horizontal
tangent to the chin (Pog) and upper lip (Ls) with line with the patient in NHP. Soft tissue Pogonion
the soft tissue N-Pog line. Holdaway said the ideal should be 0 ± 2 mm to Meridian line.
face has an H-angle of 7° to 15°, which is dictated
• Holdaway angle: Formed between the Pog -lip
by the patient’s skeletal convex¬ity. Normally, the
superioris line and N-Pog. The average value is 15°.
lower lip is located 0 to 0.5 mm anterior to the H
line. • Profile line or Z angle (of Merrifield). A tan-
gent to the chin and vermilion border of the most
4. Analysis of upper lip to nose relationship
prominent lip should ideally intersect with Frank-
This can be assessed using nasolabial angle which is formed fort horizontal at 80°+9° (Merrifield (Merrifield,
by the intersection of the upper lip anterior and columella at 1966).
Subnasale. The average value of this angle is 85°-120° (Fish
• Kole analysis which uses two lines, the first
and Epker, 1980). It can be divided by true horizontal at Sub-
from the prominent part of the upper lip perpen-
nasale point into two angles. The upper one represents nasal
dicular to SN. While the other line extends from
angulation which is 28°, and the lower angle represents up-
Orbitale perpendicular to SN. The soft tissue Pog
per lip angulation which is 85°. An acute nasolabial angle is
should be in the middle of these two lines.
an indication of a protrusive lip. An obtuse nasolabial angle
implies a retrusive upper lip or an upright nose. In general, 6. Relationship of chin to submental plane
NLA depends on:
This can be undertaken using:
• Columella orientation.
• Lip-chin-submental plane angle: It has an value of 90–
• Anteroposterior position of maxillary incisors. 110 °. Its value increases in cases with thick lower lip,
increased submental fat presence, mandibular retrog-
• Inclination of ULS.
nathia, retrogenia, and lower lip projection due to pro-
• Anteroposterior position of the maxilla. clined LLS.
• The morphology of the upper lip. • Submental plane length: It represents the distance from
soft tissue menton to junction of submental plane and
• The vertical position of the nasal tip.
vertical plane of the anterior aspect of the neck.
5. Analysis of the mandibular area
Smile analysis (mini-aesthetics) and its components
These include:
A. Smile arc: It is defined as the contour of the maxillary
• Assessment of the AP lip position using TVL (lower lip anterior teeth incisal edges relative to the curvature of
normally lies 0.5mm-2mm behind the TVL), E-line (the the lower lip during a social smile. Ideally, the contour
lower lip lies 2 mm behind this line in adults) or S-line of these teeth should match that of the lower lip. If the
(Both lips should touch this line). lip and dental contours match, they are said to be conso-

nant. The lip to lower incisor relationship in determining 2. Gingival Heights, Shape and Contour
smile arc depends on a number of factors including:
Generally, the central incisor has the highest gingival level,
• Soft tissue factors such as upper lip length and the ‘smile the lateral incisor is approximately 0.5 mm lower and the
curtain’ which is defined as the muscular capacity to canine gingival margin again is at the central incisor level. A
raise the upper lip. discrepancy in the gingival height may be due to periodon-
tal diseases, teeth attrition, ankylosis, severe crowding or
• Skeletal factors such as the vertical position of the an-
delayed maturation of gingivae.
terior maxilla (the more inferior the position of the an-
terior maxilla, the greater the exposure of the maxillary 3. Connectors
incisors, and vice versa) and the anteroposterior position
The connector includes the contact point and the areas above
of the anterior maxilla (the more anterior the position
it. The normal connector height is greatest between the cen-
of the anterior maxilla, the greater the exposure of the
tral incisors (50% of the height of teeth) and diminishes from
maxillary incisors, and vice versa).
the central to the posterior teeth (ratio for central and lateral
• Dental factors such as the vertical position of the incisor incisor connector is 40% of central incisor height; ratio for
teeth, the anteroposterior position of the incisor teeth, lateral incisor and canine connector is 30% of central incisor
the inclination of the maxillary incisor teeth (retroclina- height).
tion of proclined maxillary incisors towards the correct
4. Embrasures and black triangles
inclination increases the incisor exposure), and maxil-
lary incisor crown length, including the presence of in- The embrasures are triangular spaces gingival and incisal to
cisal wear. the connectors. The gingival embrasures are filled by the in-
terdental papillae. Short interdental papillae leave an open
• Gingival factors such as the vertical level of the gingi-
gingival embrasure, also known as “black triangles”. Cur-
val margins on the labial surface of the maxillary incisor
rent data indicates that lay detect open gingival embrasures
crowns.
of 3 mm or more and judge them as unaesthetic (Kokich et
B. Width of smile (Buccal corridor) al., 1999). Black triangles in adults usually arise from loss of
gingival tissue and supporting bone related to periodontal
Buccal corridor is defined as the negative lateral space be-
disease. When crowded and rotated maxillary incisors are
tween the buccal surface of the distal-most maxillary molar
corrected orthodontically in adults, the connector moves in-
and the angle of the mouth on smiling. The ideal width of
cisally and black triangles may appear. For that reason, both
buccal corridor is 11.5 (5-16 mm/17% total smile). Factors
actual and potential black triangles should be noted during
affecting buccal corridor are:
the orthodontic examination, and the patient should be pre-
• Arch form: A broad arch form will result in decreased pared for reshaping of the teeth to minimize this aesthetic
buccal corridors and vice versa. problem. The methods to minimise black triangle are:
• AP position of the maxilla: AP maxillary deficiency leads • Interproximal reduction
to increased buccal corridors and an unaesthetic smile.
• Relocating contact points by crown contouring or restor-
• Transverse maxillary deficiency which results in an in- ative dentistry.
creased negative space.
• Cosmetic restorations
• Palatally inclined maxillary posterior teeth.
• Correcting tooth angulation.
• Wide commissure.
• Tooth extrusion to relocate alveolar crest more inciso-
Dental Appearance (Micro-Esthetics) occlusally.
1. Tooth Proportions 5. Tooth Shade and Color
The apparent widths of the anterior maxillary teeth on smile, The shade of the teeth changes with age. Teeth appear lighter
and their actual mesio-distal width, differ because of the cur- and brighter at a younger age, darker and duller as aging pro-
vature of the dental arch. Particularly, only a portion of the gresses; this is related to the formation of secondary dentin
canine crown can be seen in a frontal view. Ideally, the appar- and thinning of the facial enamel, resulting in a decrease in its
ent width of the lateral incisor (as one would perceive it from translucency and a greater contribution of the darker under-
a direct frontal examination should be 62% of the width of lying dentin to the shade of the tooth. The maxillary central
the central incisor, the apparent width of the canine should incisors tend to be the brightest while smiling, while the ca-
be 62% of that of the lateral incisor, and the apparent width of nines are the least bright. The first and second premolars are
the first premolar should be 62% of that of the canine. lighter and brighter than the canines, more closely matched
the lateral incisors.

Other dental features In terms of posterior crossbite, there is variation in the
description between different schools of thought. British
1. Overjet: It is the horizontal overlap of the incisors. The
school considers the mandible as a reference jaw when
average value given is 2-4 mm (Cobourne and DiBiase,
defining posterior crossbite in contrary to the Americans
2015, Proffit et al., 2018). The difference might be due
who consider the maxilla as a reference. Therefore, in the
to measuring technique in the British and ABO systems.
UK, a posterior lingual crossbite means that the palatal
According to British standards overjet is measured from
cusps of the maxillary dentition are occluding buccally
the labial surface of the most prominent maxillary in-
to the buccal cusps of the mandibular dentition which is
cisor to the labial surface of the mandibular incisors.
opposite to the definition adopted in North America. To
According to ABO overjet is measured between two
avoid confusion, the glossary of orthodontic terms uses
antagonistic anterior teeth (lateral or central incisors)
the terms maxillary buccal crossbite for maxillary teeth
comprising the greatest overjet and is measured from the
which are more buccal and maxillary lingual crossbite
facial surface of the most lingual mandibular tooth to the
for maxillary teeth which are more lingual.
middle of the incisal edge of the more facially positioned
maxillary tooth. Proffit (Proffit et al., 2018) classified 4. Occlusal plane: Upper and lower occlusal planes should
overjet of Class II cases as follows: be assessed using a fox bite or wooden tongue depressor
and should be parallel to the interpupillary line in the
• Mild = 3-4 mm
absence of vertical orbital dystopia, otherwise, they are
• Moderate = 5-6 mm described as a cant. In the presence of orbital dystopia,
the true horizontal should be used. In this case a direct
• Severe = 7-10 mm
evaluation is difficult and it is better to take a photograph
• Extreme = > 10 mm with the patient biting on the wooden plate and then as-
For Class III cases, overjet is classified into: sess it. Upper and lower occlusal planes are subdivided
into anterior and posterior (Bell, 1980).. The posterior
• Mild = 0 mm cant represents a skeletal problem while the anterior cant
• Moderate = -1to -2mm represents a dental problem, or it might be secondary to
the posterior cant.
• Severe = -3 to –4mm
5. Maxillary dental midline: It should be assessed in rela-
• Extreme = > -4 mm tion to middle of the philtrum of upper lip (Cupid’s bow)
2. Overbite: It is the amount of vertical overlap of maxillary and to the facial midline. According to a systematic re-
incisors over mandibular incisors. The normal range is view (Janson et al., 2011), a dental midline deviation of
2-4 mm or 1/3 to ½ of the lower incisal crown height. A 2.2 mm can be considered acceptable by both orthodon-
complete overbite represents the overbite relationship in tists and laypeople, whereas the axial midline angulation
the presence of positive contact between the opposing of the incisors should not exceed 10° (2 mm measured
incisors or the incisors and opposing mucosa. Incom- from the midline papilla and the incisal edges of the inci-
plete overbite represents a lack of contact between the sors).
opposing incisor or mucosa despite the positive vertical. 6. Mandibular dental midline: It is assessed in relation to
While the traumatic bite is a subtype of complete over- midpoint of chin and to the facial midline and in relation
bite with evidence of trauma to either the palatal mu- to the maxillary dental midline.
cosa or to the gingivae of the lower labial segment.Proffit
(Proffit et al., 2018) suggested 2 mm as a normal value 7. Space Analysis: Please refer to the relevant chapters
for an overbite, beyond this value, the term deep bite is
used. Hence, an overbite of 3-4 mm is classified as mod-
erate deep bite, 5-7mm as severe deep bite and greater
than 7mm as an extreme deep bite. On the other hand,
open bite is defined as a lack of vertical overlap between
upper and lower incisors. Open bite is classified into: a)
Moderate = 0 to -2mm, b) Severe = -2 to -4mm and c)
Extreme = >-4 mm.
3. Transverse buccal relationship: The maxillary dentition
should overlap the mandibular dentition, a deviation
from this relationship is considered as a crossbite. There
are two main types of crossbite: anterior and posterior
crossbite. Anterior crossbite is also called reverse overjet.

Exam Night Review Factors affecting lip incompetency
Clinical facial, smile and dental analysis • With aging, the lip incompetency is reduced
Factors that affect the values during CFA • Short lip
• Racial background • Increased lower anterior face height (LAFH) due to ver-
tical maxillary excess VME
• Cultural difference
• Increased LAFH due posterior growth rotation,
• Gender
• Over-eruption of the buccal segment,
• Personal preference
• Anteroposterior (AP) skeletal malrelationships.
• Clinician philosophy
• Proclined upper labial segment (Paulsen et al.) or lower
Common Landmarks used in Facial Anthropometry
labial segment (LLS)
• Inferior Labrale Superius (ILs): A landmark on the up-
Smile arc
per lip located midway between Labrale Superius and
Stomion Superius. • Contour of the maxillary anterior teeth incisal edges
relative to the curvature of the lower lip during social
• Labrale inferius (Li) : A point indicating the muco-cu-
smile. Perhaps a better way of stating it would be “The
taneous border of the lower lip.
arc formed by a line passing through the the incisal edges
• Labrale superius (Ls) : A point indicating the muco- of the maxillary anterior sextant”
cutaneous junction of the upper lip and philtrum.
• For best appearance, the contour of these teeth should
• Nasion (N): The point in the midline of both the nasal match that of the lower lip → consonant smile.
root and the nasofrontal suture, always above the line
Factors affecting buccal corridor
that connects the two inner canthi, identical to bony na-
sion. a. Arch form
• Pogonion (Pog): The most anterior midpoint of the b. Anterior posterior position of the maxilla
chin, located on the skin surface in front of the identical
c. Transverse maxillary deficiency
bony landmark of the mandible.
d. Expansion of the maxillary arch → reduce negative space.
• Pronasale (Prn) : The most protruded point of the apex
Excessive expansion → may result in complete elimina-
nose identified in lateral view of the rest position of the
tion of the buccal corridors
head.
e. Palatally inclined maxillary posterior teeth → increased
• Soft tissue A point: The deepest midline point on the
buccal corridors.
upper lip, which is located usually halfway between Sn
and Ls. f. Wide commissure
• Soft tissue B point: The deepest midline point on the Dental midlines
labiomental fold, which determines the lower border of
• Maxillary dental midline is assessed in relation to middle
the lower lip or the upper border of the chin.
of philtrum of upper lip (Cupid’s bow) and to the facial
• Subnasale (Sn) : The midpoint of the angle at the colu- midline.
mella base where the lower border of the nasal septum
• Mandibular dental midline is assessed in relation to mid-
and surface of the upper lip meet.
point of chin and to the facial midline and in relation to
• Superior Labrale Inferius (SLi) : A landmark on the maxillary dental midline.
lower lip located midway between Stomion Inferius and
• According to a systematic review (Janson et al., 2011) a
Labrale Inferius.
dental midline deviation of 2.2 mm can be considered
Frontal facial analysis acceptable by both orthodontists and laypeople, whereas
incisors axial midline angulation should not exceed 10°
• Vertical analysis of the frontal view
(2 mm measured from the midline papilla and the incisal
• Transverse analysis of the frontal view edges of the incisors)
• Profile analysis Mixed Dentition Analysis
• Smile analysis In mixed dentition space analysis, mesiodistal width of

unerupted canine and premolars is predicted. Reference
• Direct measurement from radiographs ARNETT, G. W. 2004. Facial and dental planning for orthodontists
and oral surgeons.
• Prediction equation and/ or table
ARNETT, G. W. & BERGMAN, R. T. 1993a. Facial keys to orth-
• Combination of radiograph and prediction equation odontic diagnosis and treatment planning--Part II. Am J Orthod
Dentofacial Orthop, 103, 395-411.
• Moyers Probability Method
ARNETT, G. W. & BERGMAN, R. T. 1993b. Facial keys to orth-
• Tanaka and Johnston Method odontic diagnosis and treatment planning. Part I. Am J Orthod
Bolton analysis Dentofacial Orthop, 103, 299-312.
ARNETT, G. W. & GUNSON, M. J. 2004. Facial planning for ortho-
• Indicates ideal proportions b/w upper & lower teeth to
dontists and oral surgeons. Am J Orthod Dentofacial Orthop, 126,
achieve adequate occlusion.
290-5.
• Etrinsic factors such as sexual dimorphism, racial and ARNETT, G. W., JELIC, J. S., KIM, J., CUMMINGS, D. R., BERESS,
ethnic variations, type of malocclusion, inclination of A., WORLEY, C. M., JR., CHUNG, B. & BERGMAN, R. 1999. Soft
anterior teeth, incisor edge thickness, and the smile arc tissue cephalometric analysis: diagnosis and treatment planning of
can affect this proportionality, usually requiring adjust- dentofacial deformity. Am J Orthod Dentofacial Orthop, 116, 239-
ments in the anterior ratio, as described by Bolton. 53.
Bolton overall ratio (BOR) with the application of the sub- BASS, N. M. 2003. Measurement of the profile angle and the aes-
sequent principle. thetic analysis of the facial profile. J Orthod, 30, 3-9.
BELL, W. H. 1980. Surgical correction of dentofacial deformities.
• BOR (Bolton overall ratio) = sum of the mandibular 12/
sum of the maxillary 12 ×100 (Mean 91.3% +1.91) BOLTON, W. A. 1958. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. The Angle Orthod, 28,
• BAR (Bolton anterior ratio) =sum of the mandibular 6/ 113-130.
sum of the maxillary 6 × 100 (Mean 77.2%+1.65)
BURSTONE, C. J. 1958. The integumental profile. Am J Orthod 44,
1-25.
BURSTONE, C. J. 1967. Lip posture and its significance in treatment
planning. Am J Orthod, 53, 262-84.
COBOURNE, M. T. & DIBIASE, A. T. 2015. Handbook of ortho-
dontics, Elsevier Health Sciences.
COOKE, M. S. & WEI, S. H. 1988. The reproducibility of natural
head posture: a methodological study. Am J Orthod Dentofacial Or-
thop, 93, 280-8.
ENDO, T., UCHIKURA, K., ISHIDA, K., SHUNDO, I., SAKAEDA,
K. & SHIMOOKA, S. 2009. Thresholds for clinically significant
tooth-size discrepancy. Angle Orthod, 79, 740-6.
EXCELLENCE, N. I. F. C. 2000. Guidance on the extraction of wis-
dom teeth. Spiring Gardens. London: NICE.
FARKAS, L. G., HRECZKO, T. A., KOLAR, J. C. & MUNRO, I. R.
1985. Vertical and horizontal proportions of the face in young adult
North American Caucasians: revision of neoclassical canons. Plast
Reconstr Surg, 75, 328-38.
FISH, L. C. & EPKER, B. J. J. O. C. O. J. 1980. Surgical-orthodontic
cephalometric prediction tracing. 14, 36.
GONZÁLEZ-ULLOA, M. & STEVENS, E. 1968. The role of chin
correction in profileplasty. Plast Reconstr Surg, 41, 477-86.
HIXON, E. H. & OLDFATHER, R. J. T. A. O. 1958. Estimation of the
sizes of unerupted cuspid and bicuspid teeth. 28, 236-240.
JANSON, G., BRANCO, N. C., FERNANDES, T. M., SATHLER, R.,
GARIB, D. & LAURIS, J. R. 2011. Influence of orthodontic treat-
ment, midline position, buccal corridor and smile arc on smile at-

tractiveness. Angle Orthod, 81, 153-61.
KOKICH, V. O., JR., KIYAK, H. A. & SHAPIRO, P. A. 1999. Com-
paring the perception of dentists and lay people to altered dental
esthetics. J Esthet Dent, 11, 311-24.
LUNDSTRÖM, F. & LUNDSTRÖM, A. 1992. Natural head position
as a basis for cephalometric analysis. Am J Orthod Dentofacial Or-
thop, 101, 244-7.
MENEGHINI, F. & BIONDI, P. 2012. Clinical facial analysis: ele-
ments, principles, and techniques, Springer Science & Business Me-
dia.
MERRIFIELD, L. L. 1966. The profile line as an aid in critically eval-
uating facial esthetics. Am J Orthod, 52, 804-22.
MOORREES, C. 1958. Natural head position a basic consideration
in the interpretation of cephalometric radiographs. Am. J. Phys. An-
throp., 16, 213-234.
MOSS, J. P. 1975. An investigation of the muscle activity of patients
with Class II Division 2 malocclusion and the changes during treat-
ment. Trans Eur Orthod Soc, 87-101.
MOYERS, R. E. 1958. Handbook of orthodontics for the student and
general practitioner, Year Book Publishers.
NAIDU, D., SCOTT, J., ONG, D. & HO, C. T. 2009. Validity, reli-
ability and reproducibility of three methods used to measure tooth
widths for bolton analyses. Aust Orthod J, 25, 97-103.
NAINI, F. B. & GILL, D. S. 2008. Facial aesthetics: 2. Clinical assess-
ment. Dent Update, 35, 159-62, 164-6, 169-70.
PAULSEN, H. U., ANDREASEN, J. O. & SCHWARTZ, O. 1995.
Pulp and periodontal healing, root development and root resorp-
tion subsequent to transplantation and orthodontic rotation: a long-
term study of autotransplanted premolars. Am J Orthod Dentofacial
Orthop, 108, 630-40.
POWELL, N. & HUMPHREYS, B. 1984. Proportions of the aesthet-
ic face, Thieme medical pub.
PROFFIT, W. R., FIELDS, H. W., LARSON, B. & SARVER, D. M.
2018. Contemporary orthodontics, Elsevier Health Sciences.
RICKETTS, R. M. J. U. R. O. 1979. Bioprogressive therapy.
SHEEN, J. H. & SHEEN, A. P. 1987. Aesthetic rhinoplasty, Mosby
Incorporated.
SOLOW, B. & TALLGREN, A. 1971. Natural head position in stand-
ing subjects. Acta Odontol Scand, 29, 591-607.
STAHLE, H. J. H. O. A. 1959. The determination of mesiodistal
crown width of unerupted permanent cuspids and bicuspids. 3, 14-
17.
STALEY, R. N. & KERBER, P. E. 1980. A revision of the Hixon and
Oldfather mixed-dentition prediction method. Am J Orthod, 78,
296-302.
TANAKA, M. M. & JOHNSTON, L. E. 1974. The prediction of the
size of unerupted canines and premolars in a contemporary orth-
odontic population. J Am Dent Assoc, 88, 798-801.

2
Imaging In
Orthodontics:
Radiography &
Photography
Written by: Mohammed Almuzian, Haris Khan,Taimoor Khan, Awrisha Tariq, Syed A. A. Bukhari, Amna
Sabeeh Noor
In this Chapter
1. Goals of imaging 17. Bolton template analysis
2. Classification of imaging techniques 18. 3D cephalometric superimpositions
3. Radiographic imaging techniques 19. Computed tomography (C.T.)
4. Essential legal requirements of IRMER 2000 20. Cone Beam Computerized Tomography (CBCT)
5. X-Ray variables 21. Frontal cephalometry/ posteroanterior view
6. Measurements of radiation doses 22. Radionuclide imaging
7. Digital radiography 23. Non-ionizing imaging techniques
8. Image receptors – film and digital 24. 3D digital study models
9. Periapical radiographs 25. Stereo photogrammetry
10. Bitewing radiographs 26. Laser scanning
11. Orthopanoramic radiography (OPG) 27. Structured light imaging
12. Lateral cephalogram 28. EXAM NIGHT REVIEW
13. Projection error
14. Template analyses
15. Pitchfork analysis
16. Pancherz analysis
Isomething
maging is the process of making a visual representation of
Key aspects of IRMER 2000
The main aspects are:
(the creation of an image).
Goals of imaging • Justification must be based on the aim of exposure,
potential benefits, risks,diagnostic needs, the efficacy,
These include: benefits and risks of alternative techniques.
• Obtaining an image of the region of interest (Graber et • Optimization: This refers to reducing the ionizing dose
al., 2016). as low as reasonably practicable (ALARP) by increasing
• Viewing the area of interest in at least two planes at the KV, using digital film, fast speed film, collimator,
right angles to each other. film holder, staff training and regular quality assurance.
• Obtaining images with maximum detail, minimal dis- • Pregnant staff should not receive more than 1 mSv of
tortion, and minimal superimposition, radiation to the abdomen, and should consult radiation
protection advisor if taking more than 150 radiographs
Classification of imaging techniques per week.
There are two main types of imaging techniques, two and • 2 meter distance should be maintained from the pri-
three-dimensional images. Conventional radiographs are mary X-ray beam to operating staff.
two-dimensional images of a three-dimensional objects,
while three-dimensional imaging reflects the true form of • Lead aprons are no longer justified for routine use
the object under consideration in a 1:1 image to size ratio. in dental photography and its use during panoramic
There are several types of imaging techniques such as ra- radiography is positively discouraged. (Guidelines on
diography, clinical photography, digital, video, and optical. Radiology Standards in Primary Dental Care. NRPB/
Imaging techniques can be also categorised into ionizing RCR Working Party 1994)
and non-ionising imaging techniques. • Finally, there is no requirement of routine thyroid collar
Radiographic imaging techniques use.
Wilhelm Rontgen discovered X-rays in 1895. Since then, X-Ray variables

there have been rapid advances in imaging technology. First These include:
dental radiograph was taken within 2 weeks of discovery
of X-ray by Dr. Otto Walkoff (Germany) and Dr. Frank • Kilo voltage (kV): It is the potential difference across
Harrison (UK). In 1921, the first formal recommendation an x-ray tube, which determines the speed with which
of radiation protection in the U.K. were published by the electrons travel in the tube. Intraoral x-ray machines
British X-ray and Radium Protection Committee. In 1928, produce kV between 65-70, while extraoral machines
the International Commission on Radiological Protection produce kV that ranges from 70-120. kV determines
(ICRP) was established. the quality of the x-ray beam, which is the energy of
photons and penetrating power of photons. The higher
Radiation guidelines the kV, the more likely the photon could pass through
In clinical orthodontics, all radiation doses must be kept as the patient. kV also reduces the dose of x-rays as more
low as reasonably practicable (ALARP), and X-rays should photons pass through the patient, which reduces expo-
only be prescribed with clinical justifications. In the UK, sure time. kV affects the contrast of film in an inverse
taking x-rays is governed by some regulatory bodies includ- relationship. If kVs increase, the contrast is reduced
ing: between different tissues as more x-rays pass through
calcified tissue as well as non-calcified tissues. Increas-
• The Ionising Radiations Regulations 1999 (IRR 99) ing or decreasing the kV changes the amount of radia-
which is concerned with the safety of the workers and tion exposure.
the general public.
• Miliamp (mA) and time (s): Milliamp is the current
• The Ionising Radiation Medical Exposure Regulations flowing through the tube that is the number of elec-
2000 (IRMER) which is concerned with the protection trons circulating. Mostly, 7-12 mA is used for intraoral
of patients. radiography. Milliamp determines the quantity of x-ray
• Health Protection Agency. photons and it also affects the blackening of the film
as the overexposed film is too black. As the mAs is de-
• European commission for CBCT (SEDENTEX 2011). creased, the amount of radiation decreased. Milliampes
• The British Orthodontic Society guidelines (Isaacson and exposure time have an inverse relationship.
and Thom, 2015). Measurements of radiation doses
14 Imaging In Orthodontics: Radiography And Photography

• Absorbed Dose (D): It is a measurement of the amount network.
of energy absorbed from the x-ray beam per unit mass
• More environmentally friendly with reusable plates and
of tissue. D dose is used to assess the potential for
no processing chemicals (Brennan, 2002).
changes in the tissues. It is measured in Joules/kg, the
standard international (S.I.) unit is the Gray (Gy). • Some software programs have ‘audit trail’ features,
which can track and recover original RAW images.
• Equivalent dose (H): It is a measurement of radiation
dose that takes into account damage caused by different • Image enhancement is possible to improve the diagnos-
types of radiation. Each type of radiation is allocated a tic quality of digital images (Forsyth et al., 1996b).
different radiation weighting factor (W.R.). X-rays and
gamma rays have a weighting factor of 1, while the more
damaging protons and alpha particles have a weighting X-ray Effective Risk of Equivalent
factor of 2 and 20, respectively. H dose is calculated by dose cancer background
multiplying the radiation absorbed dose (the amount of Technique
radiation
energy absorbed by the tissue) by the radiation weight- (µSv) Per million
(days)
ing factor (W.R.) for the type of radiation being used. It
is used to assess the amount of potential damage from
Intraoral ≤10 ≤0.5 1/4th of a
the radiation to the tissues. The standard international
radiograph day
unit is the Sievert (Sv). H = D x radiation weighting
(bitewing
factor (Sievert).
and periapi-
• Effective dose (E): It is a measurement of radiation cal)
dose that takes into account the sensitivity of X-rays by Anterior 8 ≤0.5 1.2 days
different tissues of the body. Each radiosensitive tissue maxillary
/ organ in the body is given a specific tissue weighting occlusal
factors. When an exposure involves one of these tissues,
Panoramic ≤30 ≤2 0.5-5 days
the equivalent dose is multiplied by the appropriate tis-
sue weighting factor (Wt) to provide an effective dose. Lateral ≤3 ≤1 1/3rd of a
This dose can be used to compare absorption capacity cephalomet- day
of different parts of the body. It is used to assess the ric radio-
potential long term effects of the radiation dose. The ef- graphs
fective annual natural exposure to background radiation Cross- Very wide Very wide -
is approximately 2400 μSv at sea level (ranges from 1000 sectional range but range but
to 3000 μSv). Consequently, the natural background tomography ≤189 ≤14
radiation is estimated to be about 0.08 mSv per day. (single slice)
The radiation dose of CBCTs is 2 to 6 times higher than Cone beam Very wide Very wide 26 days
plane radiographs. For CBCT lateral cephalograms Vs CT (doses range but range but
plane lateral cephalograms, the radiation dose is 15 to for full field typically ≤50
26 times higher (Signorelli et al., 2016). E= H x tissue of view) between ≤50
weighting factor (Sieverts). and ≤ 500
Digital radiography CT scan Very wide Very wide 15-455 days
Digital images need to be securely saved and backed up to mandible range but range but
an appropriate computer / cloud / server. In most hospitals, ≤3300 ≤250
this storage is accomplished using a Picture Archiving & Chest 20 2 3 days
Communication System (PACS). Benefits of digital radiog- Barium 1.5mSv - -
raphy over conventional one are (Forsyth et al., 1996a): swallow
• Electronic storage and transmission. Barium 2.2mSv - 390 days
enema
• Reduced processing time and reduced clinic time.
CBCT small 10-67 - 4-10 days
• Reduced radiation exposure of up to 30-50%. vol
• The identical image can be viewed on different displays. CBCT large 30-1100 - 10-42 days
• Image can be transferred for seeking opinions. vol
• Fast transfer to remote locations via an appropriate
Imaging In Orthodontics: Radiography And Photography 15

Tissue weighting factor of important organs (Wt) ment operating at less than 70kV should include 1.5 mm
of aluminum filtration, and 2.5mm if working over 70kV.
Salivary glands 0.01 Equipment should ideally include rectangular collimation
Skin 0.01 (40 x 50mm), but if circular beams are used, they should
Thyroid 0.04 not exceed 60 mm in diameter. Equipment should also have
film speed controls, adjustable kV, mA, and exposure times.
Gonads 0.08
Equipment should ideally have D.C. or constant potential
Breast 0.12 output. Focal spot position should be marked on the tube
Red Bone marrow 0.12 head casing. The focus-to-skin distance (FSD) should be a
minimum of 200 mm.
Disadvantages of digital radiographical imaging
Occlusal radiographs
These include:
Occlusal radiographs are particularly useful in the maxillary
• An initial outlay of costs to convert from conventional
arch for assessing root form/ shape of the incisors, presence
imaging systems (Brennan, 2002).
of midline supernumerary teeth and location of impacted
• CCD systems can be bulky and have fibre optic wires, canine position, either alone or in combination with ad-
which can be damaged during use. ditional views using the parallax technique. For occlusal ra-
diographs, the film is placed between occlusal surfaces. The
• Cross infection control has to be managed.
normal angulation of the x-ray tube is 60-65 degrees to the
• Medicolegal concerns could arise from manipulatied true horizontal plane, which is increased to 70-75 degrees
images. for vertical parallax (Jacobs, 1999).
Image receptors Periapical radiographs
These include: Periapical radiographs are useful for the detection and as-
• Conventional radiographic film: It could be direct ac- sessment of local pathology, root form, root resorption, api-
tion or packet film (intra-oral) or indirect action film cal disease, presence and position of unerupted teeth. They
that is used in conjunction with rare-earth intensifying can also be used with the parallax technique, for example
screens in a cassette (extra-oral). In terms of receptors, in identifying the buccolingual position of impacted upper
there are two types of receptors for direct digital image canines and supernumerary teeth. Two methods of parallax
acquisition: charge-coupled devices (CCD) and storage can be used:
phosphor (S.P.) image plate (Isaacson and Thom, 2015). • Vertical parallax: A single periapical radiograph along
• Phosphor plate: An example of phosphor plate is the with another radiographic view, such as an upper stan-
photostimulable phosphor plates which typically consist dard occlusal or DPT
of a layer of barium fluorohalide phosphor on a flexible • Horizontal parallax: Two periapical radiographs are
plastic support. Suitable size phosphor plates are avail- taken with horizontal tube shift (at least 20 degrees) be-
able for all dental radiographic techniques. Following tween them. Horizontal parallax has a higher sensitivity
exposure, the plates are read by a laser scanning device in detecting impacted canines of 83%, when compared
to present images on a monitor. to vertical parallax of 68% (Armstrong et al., 2003).
• Solid-state sensors: It consist of a scintillator that con- Bitewing radiographs
verts x-radiation to light. The scintillator is mounted
Bitewings are accurate in the detection of interproximal car-
on a photodetector and the associated electronics are
ies, assessment of existing restorations and for periodontal
encased in a small, thin, flat, rigid, plastic rectangular
status. Bitewings may be indicated to check the caries status
housing. The underlying technology of solid-state sen-
of a high-risk patient, who need fixed appliance treatment.
sors involves either amorphous silicon-based charge-
coupled devices (CCD) or complementary metal-oxide Orthopanoramic radiography (OPG)
semiconductors (CMOS). Suitably size sensors are
OPG employs the principle of tomography or sectional
available for periapical/bitewing, panoramic, and skull
radiology (Quintero et al., 1999). Accurate positioning of
radiography. After exposure, the image processes and
patient is ensured by light beam markers. The main purpose
appears instantly on a monitor.
of OPG are:
Setting the chair-side dental X-ray equipment
• To confirm the presence, position, and morphology of
The operating range should be in the range of 60-70kV unerupted teeth.
and operate within 10% of the stated or selected kV. Equip-
• To provides an overview of developing dentition spe-

cially 3rd molar (Isaacson and Thom, 2015). • It should include triangular collimation, facilitated by a
light beam diaphragm, to reduce X-ray exposure to the
• To assess the angulation of roots can be assessed.
cranium and neck.
• Screening of frank pathology before commencement of
• The collimated X-ray source is 5 feet from the midsagit-
orthodontic treatment.
tal plane of the patient.
OPG machine should have a range of tube potential set-
• It should include an aluminium wedge filter, ideally at
tings, preferably from 60 to 90 kV. Beam height should not
the X-ray tube head, to facilitate the imaging of the soft
be higher than the image receptor in use (usually 125mm or
tissues.
150mm). Equipment needs to be provided with patient posi-
tioning aids, incorporating light beam markers. New equip- • The film should be placed 1 foot behind the midsagittal
ment should offer facilities to field-limitation techniques and plane of the patient, to minimize magnification, with a
appropriate collimation of OPG images, such as ‘dentition rare earth metal intensifying screen.
only’ which results in a 50% dose reduction.
Indications and applications of lateral cephalogram
Shortcomings of OPG
These include:
These include:
• Diagnosis and treatment planning.
• Lack of sharpness due to various factors including
• Baseline for monitoring treatment progress.
ghost imaging, superimposition, static distortion, and
processing errors. • Cephalometric radiographs can help in the location and
assessment of unerupted, malformed, and misplaced
• Horizontal distortion tends to be a non-linear distor-
teeth.
tion.
• Assess upper incisor root length.
• The vertical distortion is considered to be twice as sig-
nificant at image distortion as horizontal distortion. • Assess skeletal pattern.
• Superimposition of the cervical spine. • Serial lateral cephalograms have some application in
monitoring the growth in skeletal class 3 patients, or
• Limited focal trough in the incisor region. If the lower
to assess and monitor growth by serial radiographs.
incisor region is out of the focal trough, the apices and
However, there is a lack of high-quality evidence to sup-
associated structures may be out of focus or even invis-
port the use of lateral cephalograms for the prediction
ible. Lingually-positioned roots falling outside the focal
of facial growth.
trough are usually magnified. Similarly, excessively in-
clined teeth not contained within the boundaries of the • Assessment of soft tissue profile.
focal trough may appear narrow or foreshortened on
• Airway assessment, though it is not reliable for this
the resultant image. Consequently, the anterior region
purpose.
of the OPG may be non-diagnostic and unrepresenta-
tive of the anatomy. • Research purposes.
• Only gross caries will be detected with acceptable accu- The routine use of lateral cephalometric analysis in
racy with an OPG. Therefore, caries diagnosis requires orthodontiocs is controversial. Some believe that lateral
clinical examination supplemented by bitewing radiog- cephalograms are unlikely to be required if the incisor rela-
raphy. tionship does not require significant change. Others stated
that using a cephalogram doesn’t change orthodontic treat-
Lateral cephalogram
ment planning (Devereux et al., 2011); instead, the study
Cephalogram means ‘measurement of the head’. More com- model is considered enough diagnostic information for
monly, it refers to the use of standardized skull radiograph treatment planning in 55% of Class II cases (Han et al., 1991,
to assess facial, dental, skeletal relationships and airway Rischen et al., 2013). However, in general, lateral cephalom-
analysis. The technique was developed in the 1930’s by teric radiograph are prescribed in cases that require:
Broadbent (USA) and Hofrath (Germany). Cephalogram is
• Fixed appliances in upper and lower arches, and the inci-
the most widely used imaging modality in orthodontic in-
sor position needed to be changed.
vestigation. Lateral cephalometric skull radiographs should
fulfill the following criteria: • Functional appliance therapy.
• There should be accurate patient positioning, assisted by • Class II and III malocclusion and bimaxillary protrusion.
light beam markers. • When the malocclusion is significant i.e. in a child of less

than ten years with Class 2 or 3 jaw relationship, which some are more complicated than others, the method chosen
may require early treatment or monitoring. should reflect clinical / research use) or operator error which
is influenced by experience and calibration.
• When the labiolingual movement of incisors is antici-
pated, and significant changes are to be made. Environment factors
• If the patient requires orthognathic surgery. These include lightbox, ambient light conditions, and quality
of the image.
Types of errors in cephalometric analysis
Methods to reduce measurement error
These include systematic error (due to different concepts of
landmark identification) and random error which includes These include:
projection errors, errors of identification and errors within
• Careful selection of analysis method.
the measuring system.
• Error calculation.
Projection error
• Care when interpreting results.
Projection error occurs due to 2-dimensional radiographs
representing 3-dimensional objects. Landmarks outside of • Good quality film and standardisation.
the mid-sagittal plane (para-mid-sagittal) are distorted by
Advantages of on-screen digitizing
projection error, resulting in obtuse angular measurements
and shortened linear measurements. Landmarks in the These include (Sandler et al., 2002):
midsagittal plane are unaffected. Types of projection errors • Cost saving with no requirement of lightboxes / trac-
are magnification and head position errors. Magnification ing units.
error can be quantified using calibrated metal strip / scales.
Magnification errorr for linear measurements, range from • Adjustable brightness and contrast to make identifica-
7-10% while angular measurements are unaffected. Image tion of hard and soft tissues easier.
magnification is constant for each individual machine. If • Useful teaching tool.
lateral cephalograms are produced using different machine,
there is likely a variation in magnification projection error, Assessing treatment changes using lateral cephalograms
therefore, calibration and standardisation are essential. A Analysis of changes secondary to orthodontic treatment take
short focal distance increases projection errors while long place through the superimposition of 2 or more cephalo-
focal distance decreases projection errors. gram. The facial skeleton can be assessed as a single entity
To reduce head position error, lateral cephalograms should (total facial skeleton), or each jaw can be assessed indepen-
be taken in centric relation with Frankfort plane horizontal dently. For total facial skeleton analysis, many techniques
or natural head position (NHP) as reference. It is also es- have been proposed, such as:
sential to control magnification by the correct focal object • Superimposition on S-N plane registered at S: Pre- and
distance and have correct head position. post-treatment cephalograms are superimposed on the
Landmark identification error SN reference line. S-N is an easy reference line but the
position of nasion may change due to growth at fronto-
All landmarks have an ‘envelope of error’ which is depen- nasal suture making S-N an unreliable reference line for
dent on anatomic characteristics of landmark, for instance superimposition.
points on edges of the anatomical structures are easier to
locate than points within structures. To reduce identification • Superimposition on DeCoster line: Lucien DeCoster in
errors a clear understanding of the definition is required, 1952 described the basicranial line or anterior cranial
automated or semi-automated radiographic identification of base as a stable structure, which represented the axis of
landmarks (artificial intelligence) can be used and alumini- the skull base and was therefore suitable for the com-
um wedge for better sharpness is recommended. parison of changes in the facial bones (De Coster, 2007).
The DeCoster line extends along with the anterior lip of
Registration error Sella turcica, sphenoethmoid suture, planum sphenoi-
Although registration can be manual or digital, there is no dal, the roof of the ethmoid and the cranial side of the
difference between manual and digital tracing (Santoro et frontal bone.
al., 2006, Naoumova and Lindman, 2009). • Superimposition on Björk’s stable structures: Björk and
Measurement error Skieller further defining the precise anatomical land-
marks along the anterior cranial base that should be
It is due to difference in the applied cephalometric analysis utilized on the basis of stability (Björk and Skieller,
(different methods of cephalometric analysis are available, 1983), these include the anterior wall of sella turcica

and its intersection with the anterior clinoid process, mon perpendicular line to the maxillary occlusal functional
cribriform plate of the ethmoid, frontoethmoidal crest. plane from the first tracing, which is used in the subsequent
and the cerebral surface of the orbital roofs. tracing after superimposition on the cranial base line (SN
line).
• Superimposition using Ricketts’ method: It uses the entire
length of the cranial base along a line constructed from Bolton template analysis
nasion to basion.
Bolton analysis has two forms, the schematic template which
Maxillary skeletal and dental changes assess the changes in position of selected landmarks with
age on a single template and the the anatomically complete
Maxillary superimposition allows the assessment of dental
template which uses a different template for each age. It is
changes. For maxillary skeletal and dental changes, the two
particularly convenient for direct visual comparison of a
common techniques are Björk’s and Ricketts’s method. For
patient to a reference group while accounting for age related
Björk’s method for superimposition, the anterior contour of
changes.
the zygomatic process is used as the reference line.
3D cephalometric superimpositions
Using Ricketts’ method, nasion-pterygomaxillary is used
as reference plane, registered at the pterygomaxillary point. 3D CBCT images can be superimposed by manual registra-
This point is supposed to represent the foramen rotundum, tion of landmarks or by the best fit of landmark regions.
the point of exit of the maxillary branch of the trigeminal The different methods to superimpose 3D images are
nerve from the intracranial cavity. voxel-based, landmark-based, and surface-based registra-
tion (Cevidanes et al., 2006). Surface-based and voxel-based
Mandibular skeletal and dental changes
superimposition methods using the anterior cranial base as
Simialr to maxillary superimposition, mandibular superim- a reference structure, and are accurate and reliable in detect-
position allows the assessment of dental changes and can be ing changes. Landmark-based superimposition method
undertaken using Björk’s or Ricketts’s method. With Björk’s is less accurate than the other methods (Ghoneima et al.,
method, the several structures are considered stable points 2017).
/ areas for registration of superimposition, these include
Computed tomography (C.T.)
anterior contour of the chin, inner contour of the symphysis,
any distinct trabecular structures in the symphysis, contour Tomography is a general term for a technique that provides
of the mandibular canal and lower contour of a mineralized an image of a layer of tissue. 3D images such as magnetic
tooth germ (premolar or molar) present in both cephalo- resonance imaging and computed tomography (C.T.). The
grams. With Ricketts’ method, registration is taken place data is recorded on solid-state image detectors arranged in
at the CC point, which is the point of intersection of a line a 360˚ array around the patient. A series of axial plane slices
constructed from the pterygomaxilla (Pt) to gnathion. are captured as individual stacked slices or from a continu-
ous spiral motion over the axial plane.
Template analyses
C.T. scan has a higher sensitivity in assessing the presence
Template analyses are a method of cephalometric analysis
of root resorption (48%) when compared with conventional
and superimposition based on the construction of a specific
radiographs (12%) (Ericson and Kurol, 2000). The sensitiv-
reference plane, which is used for both analysis and super-
ity of C.T. scan for bone mass lesions is excellent though soft
imposition.
tissue sensitivity is poor when compared to a MRI.
Pitchfork analysis
It is advisable to select the smallest field of view required for
It is a popular superimposition technique in which the refer- clinical evaluation to reduce exposure. C.T. scans for implant
ence structures is the maxilla, zygomatic plates and zygoma. placement is asscoiated with an effective dose of 30 to 650
A paper by Mannchen (Männchen, 2001), has described mSv.
some disadvantages of the pitchfork analysis including that
Cone Beam Computerized Tomography (CBCT)
the maxilla is not a stable structure on which to superim-
pose, rotational changes of the maxilla during treatment Although low-dose protocols for CBCT imaging seem to
could affect the antero-posterior assessment. Moreover, the have potential in various disciplines in dental medicine
mean functional occlusal plane can change and affect mea- ranging from pediatric dentistry to oral and maxillofacial
surements relative to it. surgery, CBCT should be used cautiously and in carefully
in selected scenarios. Dose reduction is usually achieved by
Pancherz analysis
mAs reduction, use of partial rotations, reduced number of
Pancherz analysis is similar in principal to the pitchfork projections, and larger voxel sizes, but seldom by kV reduc-
analysis. This method analyse the anterior-posterior changes tion (Yeung, 2019). It is used as an adjunct to 2D imaging to
in the maxilla, mandible and dentition. It relies upon a com- improve patient outcomes (Drage, 2018).

CBCT unit the number of roots or dens evagination.
The main features of the CBCT unit are: • Root fracture.
• In this technique, a cone-shaped X-ray beam rotates • Dental implant: Assessment of bone height, width,
around the patient to acquire volumetric data of the quality, relation with adjacent structures. implant born
region of interest with a single rotation (Merrett et al., frameworks and abutments can also now be produced
2009). using CAD/CAM technology).
• The equipment for CBCT resembles panoramic units. It • Endo-perio lesion.
involves a cone-shaped x-ray beam, flat-panel detectors
• Complicated root canal treatment.
and image intensifiers (amorphous silicon or comple-
mentary metal-oxide semiconductors). Advantages of CBCT
• The X-ray tube has a variable potential between 60- These include:
120kV.
• Less distortion than conventional 2D radiographs.
• Scan time varies from 5-90 seconds while the patient is
• Limited magnification error.
exposed to radiation for 3.5 seconds.
• Ability to correct head position after the image is cap-
• The overall effective dose has been estimated at 50 – 500
tured.
μSv depending on exposure time/ mAs.
• Less structural superimposition compared to conven-
Rationale and uses of CBCT in orthodontics
tional radiographs.
A clinical justification should be based on the risk-benefit
• Better imaging of the bone and dental hard tissue com-
ratio of radiation exposure (Oenning, 2018). Generally,
pared to C.T. scan.
CBCT should not be prescribed unless its diagnostic infor-
mation improves treatment outcomes and if plain 2D views • CBCT image helps in surgical planning by allowing the
do not show enough information for a particular clinical visualization of exact movements of jaws.
question (SEDENTEX 2011). • CBCT equipment is smaller than a C.T. equipment.
Generally, CBCT imaging is useful in cases with: • Reasonable degree of sensitivity in detecting root re-
• Impacted teeth: CBCT aids in surgical planning (Botti- sorption is 66.7% (Walker et al., 2005).
celli et al., 2011), and aid in determining the mechanics Disadvantages of CBCT
and force direction.
These include (Drage, 2018):
• Supernumerary teeth.
• High cost.
• Root resorption (Yi et al., 2017).
• Extensive training is required to fully evaluate the image
• Cleft lip and palate (Kuijpers et al., 2014b, De Grauwe et as it is a legal requirement to report on the entire image
al., 2019). taken.
• Orthognathic surgery planning: 3D surgical predic- • The patient is required to stay still for 10-40 seconds.
tions, superimpositions of treatment outcome, and
growth change evaluation in three dimensions can be • Increased artefacts, image scatter and noise which de-
performed. Surgical outcomes can be evaluated, and creases the ability to differentiate low contrast visibility
this can be of great value for the orthodontist and the tissues (Garayoa and Castro, 2013).
patient. • Beam hardening and streak artifacts around dental res-
• Assessment of RME. torations can render diagnosis (Elstrøm et al., 2011).
• Planning for miniscrew placement. • Low dose CBCT X-rays can result in low quality images.
• Airway analysis (questionable). • There is no robust evidence showing improvement in
treatment outcomes with the uses of CBCT scans. A
• Transplantation: CBCT can be used to prepare a study in Cardiff showed that the incidental finding of a
template / 3D replica in the recipient site, as well as for CBCT which could changed the treatment plan is less
assessment of root resorption and position of teeth in than 1% (Drage et al., 2013).
the alveolar housing.
• Dental CBCT is not indicated for soft tissue analysis,
• Developmental abnormalities: Such as dilacerations, such as malignant tumours, phlegmon, and other forms

of extensive inflammation. it should be kept to the minimum level necessary (the
exposure dose for children should be about half that
Frontal cephalometry/ posteroanterior radiographs
used in adults).
Frontal cephalometry can be helpful in the assessment of
Non-ionizing imaging techniques
specific jaw or dental anomalies or functional asymmetries
and asymmetries. Digital 2D Photography
Hand or wrist radiographs Photography in dentistry began in 1840 (Galante, 2009)
while digital photography boomed in mid-1990 (Kalpana
In the UK, it is no longer necessary to take hand or wrist
et al., 2018). The purposes of dental photography (Ahmad,
radiographs to assess skeletal maturation.
2009, Kalpana et al., 2018) are:
Radionuclide imaging
• Documentation.
This procedure involves localization of regions of cellular
• Communication (patients, dentist, etc).
activity within a patient in which the patient is adminis-
tered with one or more nuclides. The common radionu- • Diagnosis and treatment planning: It allows the ortho-
clide imaging that is used in orthodontics is Technetium 99 dontists to study the patient’s soft tissue pattern during
which is helpful in assessing current growth in patients with treatment planning phase. Lip morphology, tonicity,
facial asymmetry, and identifying ‘hot spots’ of asymmetric smile arc, and smile aesthetics from various angles can
growth. also be assessed.
Damaging effects of ionizing radiation • Self-education and reflection.
Dental radiography accounts for about 25% of all radiog- • Case presentation.
raphy in the U.K. Historically, dental radiography required
• Quality control.
high doses of radiations that produced local side effects like
skin reddening, hair loss, ulceration and cancer fatalities. • Research/teaching .
Unnecessary radiation from diagnostic radiographs cause
• Insurance verification.
100-250 UK cancer fatalities. Generally, there are three
major categories of ionizing radiation side effects on human • Marketing
tissue including: • Medico-legal purposes.
• Somatic deterministic (certainty) effects which occur Advantages of digital photography (Sandler and Murray,
when the threshold dose reached (10 Sv of total body ir- 2001)
ritation). These effects could be direct effects (abnormal
mitosis; degeneration and death of cells), indirect effects These include:
(change in tissue due to damage to blood supply or • No fading in the image quality with time.
constitutional effects (such as malaise, nausea, vomiting,
decrease blood pressure, peripheral vascular failure, also • Immediate viewing.
called radiation shock). • No film or processing costs.
• Somatic stochastic (chance or random) effects: are not • Inexpensive storage.
dose dependent, and are due to chance. This means that
the severity of damage is not dependent on the amount • Easy retrieval.
of exposure, but only the likelihood of harm being • Easy duplication.
increased. Somatic stochastic include neoplastic change
such as skin, bone sarcomas or leukaemia. Requirement of digital photography
• Genetic stochastic (random) effects are shown in DSLR (digital single-lens reflex) cameras are highly recom-
offspring of recipient. For orthodontic radiography, it is mended for taking orthodontic photographic records. DSLR
important to reduce radiation to skin, bone, bone mar- camera consists of (Hutchinson and Williams, 1999, Lozano,
row, thyroid, and salivary glands, especially in children 2015, Kalpana et al., 2018):
(Thorne, 1992). Children have higher risk from ionizing • Camera body (minimum of 4-5 Mega Pixels is re-
radiation for two reasons: firstly, due to the higher cell quired),
and tissue sensitivity to radiation than adults, secondly
due to the longer lifespan than adults in which radia- • Macro lenses (Fixed focal length of 85-105 mm, 1:2.8
tion-induced changes may manifest. Therefore, exami- Ultra Sonic Motor and Adjustable manual focus)
nation of children need to be performed carefully and • Memory card,

• Flash (A ring flash of 1/2 power or twin flash). However, al., 2004). For diagnostic purposes, the accuracy of intraoral
a lightbox behind the patient for extraoral photos is scanner systems is comparable to the accuracy of conven-
recommended. tional impressions (Abduo and Elseyoufi, 201, Luqmani et
al., 2020).
In addition, there are special retractors and mirrors which
are used with intraoral photography including: Types of intraoral imaging techniques
• U-shape cheek retractors for frontal intraoral photos. These include:
• Fishtail-shaped cheek retractors for right and left intra- • Scanner with parallel confocal imaging: With this tech-
oral photos, sometime used along with buccal mirrors. nique, the scanner projects laser light through a pinhole
to the target. The sensor is placed at the imaging plane
• T-shape lip retractors for occlusal photos along with
where it is in focus (confocal). A small opening in front
occlusal mirrors.
of the sensor blocks any light from above or below.
Camera settings and position Only the focused light reflecting off the target tissue
will reach the sensor for processing. This type of system
It is recommended to take extra-oral photographs in
creates thousands of tomographic slices and combines
portrait mode and intra-oral photographs in landscape
them together to form the three-dimensional picture.
mode. To achieve good digital dental photographs, stan-
For example iTero, Trios, Carestream.
dardisation of camera settings and patients posture is re-
quired (Hutchinson and Williams, 1999, Lozano, 2015, • Scanner with triangulation imaging: With this tech-
Kalpana et al., 2018). Camera settings are also termed the nique, the scanner measures the angles and distances
exposure triangle, depending on the type of the camera, from known points (laser source and sensor), with
but commonly include: projected laser light. It requires a thin coating of opaque
powder to be applied to the target tissue. The system
• Aperture which is defined as the opening in a lens
determines the angle of reflection and the distance from
through which light passes to enter the camera. Aper-
the laser source to the object’s surface as light reflects off
ture is represented by the F number or depth of field
the object. For example CEREC system (Chairside Eco-
(DoF). DoF refers to the aperture opening size of the
nomical Restoration of Aesthetic Ceramics or Ceramic
lens. Smaller f-number = more light and small aperture.
Construction).
For extraoral photographs f/8, smile photographs f/32
and intraoral photographs f/22 • Scanner with accordion fringe interferometry (AFI):
With this technique, two sources of light are used with
• Shutter speed is the length of time camera shutter is
AFI to project three patterns of light, called fringe
open, and the exposer of light to the camera sensor.
patterns onto the teeth and tissue (True Definition
Simply it is how long the camera spends taking a photo.
Scanner). Based on the shape of the object, the fringe
In dental photography, this should be 1/60 seconds.
pattern distorts and takes on a new pattern. Surface data
• ISO which brightens or darkens the photo. As the ISO points of the fringe curvature are recorded by a high-
increase, photo becomes progressively brighter, in den- definition video camera that is offset from the projector
tal photography, this should be 100-200. by approximately 30˚. Because of the differences among
Gold standard photos for orthodontic purpose the three precision optical measurements, the distance
of different measures is determined. The differential
Nine pre-treatment and nine post-treatment images are measurement is unaffected by changes in tooth colours
considered a minimum for orthodontic patients. This and materials.
entails four extraoral and five intraoral photos (Sandler
et al., 2002). A full set of progress photos are also rec- • Scanner with three-dimensional in-motion video: With
ommended at important stages, ideally at each arch wire this technique, the scanner utilises three tiny high-
change plus photographic details of the appliance. For definition video cameras to capture three precise views
printing and publication purposes, the minimum resolu- of the target. A sensor behind the cameras converts
tion of 150-300 PPI is required in either JPEG or TIFF the light energy into electrical signals, which allows
format. the distances between two data points to be calculated
simultaneously from two perspectives in order to create
Intraoral scanning (oral scanner) three-dimensional data. The data points are captured in
With intraoral scanning, a video camera records the struc- a video sequence and modelled in real-time. Although
tured light distortions on the dental surfaces as it passes powdering may be required to capture surface data
over the dentition. A computer processes these images and points, only a light dusting is needed, compared with
merges them to create a complete 3D dental arch (Hajeer et the thicker coating needed for triangulation. This scan-

ner was made by the Lythos Digital Impression Systems. angular values, and the detection of changes in face mor-
phology (Graber et al., 2016). This method is not suitable for
• Scanner with ClearView SCAN: With this technique,
imaging study models.
the scanner uses high-definition ultrasound imaging to
capture both the tooth, bone and soft tissue in three di- Advantages of Stereophotogrammetry
mensions. Early prototypes suggest that these scans will
These include:
use a disposable mouthpiece to scan the entire arch at
once and will be significantly faster and more accurate • Stereophotogrammetry has low cost, safe, easy to oper-
than light-based scans. This scanner is made by S-Ray ate with no radiation exposure.
Incorporated.
• The advantages of stereophotogrammetry over CBCT
3D digital study models or laser scanning are short imaging times (less than 1
second) that minimize motion errors and high colour
Digital models offer a valid alternative to plaster study casts
resolution.
(McNamara et al., 2011). A study found that 18% of practi-
tioners in the U.S use digital models (Keim et al., 2008). • Stereophotogrammetry can be combined with CBCT
images.
Digital models can be substituted for plaster models with no
significant differences in the final treatment plan, the reli- • Stereophotogrammetry allows orthodontists to evalu-
ability of the treatment plan, and the time required to create ate surface contours of a human subject rapidly and
the treatment plan (Sharma et al., 2019). The advantages of objectively.
digital study models over conventional models are (Martin
• Stereophotogrammetry is an accurate and reliable
et al., 2015):
imaging method for use in orthodontics, due to its
• Reduced requirement for model storage. high intra-observer and inter-observer reproducibility
(Dindaroglu et al., 2016).
• No physical damage comapred to conventional models.
• Stereophotogrammetry can be used for facial superim-
• Quick access to three-dimensional diagnostic informa-
positions after orthognathic surgery. Stereophotogram-
tion.
metry measurements relating the jaws to each other and
• A virtual setup can be created for treatment planning incisor orientation has a strong positive correlation with
and manufacturing of fixed and removable appliances. corresponding traditional cephalometric measurements
and can serve as cephalometric predictors.
• Smooth transmission of digital data for communication
with professionals and patients. Laser scanning
• Reliable digital model measurements (Camardella et Laser scanning is used for 3D facial scanning and construc-
al., 2020) with inter-arch and intra-arch measurements tion of digital models (Ireland et al., 2008). The first 3D
from digital models from intraoral scans are more scanning technology was created in the 1960’s in which the
reliable and accurate than conventional study models scanners used lights, cameras and projectors to perform this
(Aragón et al., 2016). A systematic review suggested task.
that digital models are as reliable as traditional plaster
Digital cameras monitor the illumination, and triangula
models, with high accuracy, reliability, and reproduc-
tion geometry allows depth information to be calculated.
ibility. Landmark identification, rather than the measur-
The light source can be a point or plane, and the face can be
ing device or the software, appears to be the greatest
moved through the light source or vice versa. This technol-
source of error. Furthermore, with their advantages in
ogy generally produces facial surfaces with accuracy and
terms of cost, time, and space required, digital models
resolution of 0.1 mm which is sufficient for detailing the
could be considered the new gold standard in current
head and face and can take up to 30-60 seconds. In laser
practice (Fleming et al., 2011) (Martin et al., 2015, De
scanning, the face is traversed by a laser light source (Hala-
Luca Canto et al., 2015)
zonetis, 2001).
Stereophotogrammetry
Laser scanning provides surface map detail, and cannot
Stereophotogrammetry uses two cameras, arranged as a provide colour information, however a colour camera that is
stereo pair, to photograph an object from two different co- registered with the laser scanner can capture colour detail.
planar planes. High-resolution images are captured at differ-
Digital cameras monitor the illumination, and triangula
ent angles, and a three-dimensional image is reconstructed.
A software system is used to view and analyze the images Advantages and disadvantages of laser scanning
(Hajeer et al., 2004).This technique allows the recognition
These include:
of different facial landmarks, the measurement of linear and

• Portability and ease of use. views of a face. A full-face model is then produced by com-
bining different perspectives to reproduce one model by a
• Laser scans generate smooth images with all facial fea-
process called stitching, which can be performed manually
tures recorded in detail.
or semi-automatically. The disadvantages of this system are
• Laser scanner is a reliable soft tissue imaging sys- long required time and the manual intervention.
tem with a maximum measurement error of <1mm
Magnetic resonance imaging and orthodontics
(Kuijpers et al., 2014a). Although the accuracy of this
technique continues to improve with time, craniofacial MRI image is produced by radio waves directed at a patient
measurements obtained with laser scanners show excel- placed in a magnetic field. MRI creates an image without us-
lent reliability and accuracy, which qualifies this method ing ionizing radiation and records soft tissues in high detail,
for clinical and scientific use.
A disadvantage of MRI is the length of time required for
• Laser scanning of study casts has many advantages over scanning. Some patients are unable to tolerate the long
other scanning techniques, despite the long-time of scanning time of the enclosed scanning space for the dura-
acquisition. Areas of the undercut can be overcome by tion of the scan. Hence, MRI is contraindicated in patients
scanning the object from different angles. with claustrophobia and those with ferromagnetic implants.
• A disadvantage is the time needed to obtain measure- Furthermore, MRI does not provide good bone details and
ments is greater than 4 minutes (de Sá Gomes et al., the metallic objects appear black (Dahllöf and Huggare,
2019). 2004). Evidence that suggests that orthodontic stainless steel
appliances can cause artefacts, hence, removal of stainless
• Safety issues are important, such as exposure of eyes to
steel orthodontic appliances prior to MRI scan is recom-
the laser beam, particularly in growing children (Kara-
mended, especially if the area of interest is near oral cavity,
tas and Toy, 2014).
however, ceramic brackets cause no distortion to the MR
• Laser scans are sensitive to light and metal objects, image (Beau et al., 2015). Multistranded stainless steel lin-
requiring careful control of the operating environ- gual retainers did not cause significant image distortions in
ment, and the speed of data capture. This can make the MR images (Zhylich et al., 2017).
processes longer and less suitable for scanning younger
Advantages of MRI
children (Halazonetis, 2001).
The major advantages include:
Optical surface scanning
• Non-ionizing radiations.
This system is based on the principle of triangulation and
utilizes a 3D optical scanning system. The rotary optical • Easy to reconstruct images in any plane with an excel-
system produces a beam of light that is fanned into a vertical lent soft tissue discrimination, and non-dependency on
line of 0.7mm width by a lens, and projected onto the face. the operator.
Optical surface scanning of soft tissues allows the three- • MRI is used for upper airway analysis and measur-
dimensional study of the face which is not possible with ing airway space especially in patients with a cleft to
cephalograms. determine velopharyngeal incompetence (Kuijpers et
al., 2014a).
The accuracy of this system greater than 0.5mm, but repro-
ducibility needs further assessment (Coward et al., 1997). • MRI is the gold standard for imaging of TMJ morphol-
The optical surface scanner has the advantage of rapid and ogy but mostly reserved for those patients with persis-
accurate data in all three dimensions (Nute and Moss, 2000). tent symptoms following conservative treatment where
Moreover, the lack of ionizing radiation allows data to be ac- surgical intervention is being considered.
quired of for research without the risks of ionizing radiation.
• MRI allows examination of inflammatory processes and
However, the major disadvantage of the system is its cost. It
scar tissues.
also has limitations in capturing undercuts in impressions,
and these scans would not form a consistently reliable bases • MRI can be safely used in patients allergic to contrast
for routine orthodontic diagnostics and treatment planning. agent.
Structured light imaging • A recent study indicated that MRI enables reliable 3D
cephalometric analysis with excellent agreement to cor-
The principle of this system is the projection of a pattern of
responding measurements on CBCT. Thus, MRI could
light (for example lines, strips) onto a surface analysis of the
serve as a non-ionizing alternative to CBCT for treat-
image distortion of light results in a the three-dimensional
ment planning and monitoring in orthodontic treat-
surface map. Images are captured from one viewpoint, so
ment as well as oral and maxillofacial surgery (Juerchott
multiple images are taken to obtain frontal, left, and right

et al., 2020). compared to CT scans, however higher Xray dose than
conventional radiographs.
Imaging of the temporomandibular joint
• Should be used cautiously and only when indicated.
These include CT scan, CBCT scan and MRI for a disc prob-
Justification of benefits of increased dose for improving
lem. As previously stated, conventional radiographs are no
diagnosis and treatment planning and when 2D cannot
longer recommended for investigating TMJ pain dysfunc-
provide the relevant information.
tion. The need to have radiographs taken in advance of treat-
ment in order to avoid possible later claims of negligence • Use of small FOV’s highly recommended.
cannot be justified.
• Overall effective dose between 50 - 500 μSv.
• Uses in orthodontics for impacted teeth, root resorp-
tion, dental anomalies, CLP & CP, orthognathic surgery
& airway assessment.
Exam Night Review Hand wrist radiographs: Are no longer recommended.
• Pregnancy---<1mSv, <150 Rg/Wk—IRMER 2000 Radionucleotide imaging: With Technetium 99 scan.
• No Thyroid collars/ Lead Aprons is needed---IRR99 Non-ionizing imaging
• 2 meters distance from Primary Beam---IRR99 • 2D digital photography.
• Storage of radiographs: BDA- 11yrs or till 25th Birth- • Intraoral scanning.

day, whichever longer • Digital models.
• Natural background radiation is estimated to be about • Stereophotogrammetry.
0.08 mSv per day
• Laser scanning.
• CBCT is about 3 to 6 times the Xray dose of digital
panoramic radiograph and 15 to 26 times the dose of • Optical surface scanning.
lateral cephalometry (Signorelli et al., 2016). • Structured light imaging.
• Accuracy of parallax: Horizontal parallax 83% v/s verti- • Magnetic resonance imaging.
cal parallax 68% (Armstrong et al., 2003)
Available evidence
Types of errors in cephalometry
• Digital radiographical imaging is more environmentally
• Systemic error. friendly as less processing chemicals and reusable plates
• Random error: Projection, identification & measuring are used (Brennan, 2002).
system. • Horizontal parallax is more sensitive in detecting
Stable references planes / point impacted canine 83% when compared to 68% vertical
parallax as assessed by dentists (Armstrong et al., 2003).
• Anterior cranial base- De Coster’s line and Björk’s
structural method. • Cephalometric tracing can be done manually or digi-
tally. Studies have shown there is minimal difference
• Maxilla: Key ridge area (anterior surface of the zygo- between the two types of tracing methods
matic process) by Björk, Superior & inferior surface of
the hard palate. • Surface-based and voxel-based superimposition
methods using the anterior cranial base as a reference
• Mandible: Anterior contour of the chin, Inner contour structure in 3D were accurate and reliable in detecting
of the symphysis, distinct trabecular structures in the changes in landmark positions when superimposing.
symphysis, contour of the mandibular canal, lower con-
tour of a mineralized tooth germ of 3rd molar. • Low-dose protocols for CBCT imaging: Dose reduction
is usually achieved by mAs reduction, use of partial ro-
• Artificial structure – implants. tations, reduced number of projections, and larger voxel
• Template analysis- Pitchfork, Pancherz & Bolton’s tem- sizes, but seldom by kV reduction.
plate analysis. • Current available evidence suggests that CBCTs could
Cone Beam Computed Tomography (CBCT) be reliable to detect the presence of ERR in clinical
practice and has higher diagnostic efficacy than periapi-
• Cone beam shaped radiation with less Xray dose when cal radiographs. (Yi et al., 2017)

• No evidence that CBCT improves outcomes of treat- References:
ment.
Abdelkarim A, Jerrold L. Clinical Considerations And Potential Li-
• For diagnostic purposes and short-span scanning, the ability Associated with The Use of Ionizing Radiation in Orthodon-
accuracy of intraoral scanner systems is comparable to tics. Am J Orthod Dentofacial Orthop. 2018;154(1):15-25.
the accuracy of conventional impressions Aragón Ml, Pontes Lf, Bichara Lm, Flores-Mir C, Normando D. Va-
lidity and Reliability of Intraoral Scanners Compared to Conven-
• A systematic review suggested that digital models are as
tional Gypsum Models Measurements: A Systematic Review. Eur J
reliable as traditional plaster models, with high accura-
Orthod. 2016;38(Ericson S & Kurol J 1987):429-34.
cy, reliability, and reproducibility. Landmark identifica-
tion, rather than the measuring device or the software, Armstrong, C., Johnston, C., Burden, D. & Stevenson, M. 2003.
appears to be the greatest source of error. Furthermore, Localizing Ectopic Maxillary Canines—Horizontal Or Vertical
Parallax? The European Journal Of Orthodontics, 25, 585-589.
with their advantages in terms of cost, time, and space
required, digital models could be considered the new Ayaz I, Shaheen E, Aly M, Shujaat S, Gallo G, Coucke W, Et Al.
gold standard in current practice (Fleming et al., 2011) Accuracy and Reliability Of 2-Dimensional Photography Versus
(Martin et al., 2015, De Luca Canto et al., 2015) 3-Dimensional Soft Tissue Imaging. Imaging Science in Dentistry.
2020;50(1):15-22.
• 3D photogrammetry measurements relating the jaws to
Abduo J, Elseyoufi M. Accuracy of Intraoral Scanners: A Systematic
each other and incisor orientation has a strong positive
Review of Influencing Factors. The European Journal of Prosth-
correlation with corresponding traditional cephalo- odontics and Restorative Dentistry. 2018;26(3):101-21.
metric measurements and can serve as cephalometric
predictors Beau, A., Bossard, D. & Gebeile-Chauty, S. 2015. Magnetic Reso-
nance Imaging Artefacts And Fixed Orthodontic Attachments. Eur
• Stereophotogrammetry was found to a reliable and J Orthod, 37, 105-10.
accurate tool for the morphological evaluation of soft
Benington, P. C., Khambay, B. S. & Ayoub, A. F. 2010. An Overview
tissue in comparison to 2D imaging and laser scanning Of Three-Dimensional Imaging In Dentistry. Dent Update, 37, 494-
• Laser scanner and stereophotogrammetry are reliable 6, 499-500, 503-4 Passim.
soft tissue imaging systems with a maximum measure- Björk, A. & Skieller, V. 1983. Normal And Abnormal Growth Of
ment error of <1mm (Kuijpers et al., 2014a) The Mandible. A Synthesis Of Longitudinal Cephalometric Implant
Studies Over A Period Of 25 Years. The European Journal Of Or-
• A recent study indicated that MRI enables reliable 3D thodontics, 5, 1-46.
cephalometric analysis with excellent agreement to cor-
responding measurements on CBCT. MRI could serve Brennan, J. 2002. An Introduction To Digital Radiography In Den-
as a non-ionizing alternative to CBCT for treatment tistry. J Orthod, 29, 66-9.
planning and monitoring in orthodontics as well as oral Camardella Lt, Ongkosuwito Em, Penning Ew, Kuijpers-Jagtman
and maxillofacial surgery. Am, Vilella Ov, Breuning Kh. Accuracy and Reliability of Mea-
surements Performed Using Two Different Software Programs on
Digital Models Generated Using Laser and Computed Tomog-
raphy Plaster Model Scanners. Korean Journal of Orthodontics.
2020;50(1):13-25.
Castillo Jc, Gianneschi G, Azer D,Manosudprasit A, Haghi A,
Bansal N, Et Al. The Relationship Between 3d Dentofacial Photo-
grammetry Measurements and Traditional Cephalometric Mea-
surements. The Angle Orthodontist. 2019;89(2):275-83.
Cevidanes Lh, Styner Ma, Proffit Wr. Image Analysis and Superim-
position Of 3-Dimensional Cone-Beam Computed Tomography
Models. Am J Orthod Dentofacial Orthop. 2006;129(5):611-8.
Coward, T. J., Watson, R. M. & Scott, B. J. 1997. Laser Scanning For
The Identification Of Repeatable Landmarks Of The Ears And Face.
Br J Plast Surg, 50, 308-14.
Dahllöf, G. & Huggare, J. Orthodontic Considerations In The Pe-
diatric Cancer Patient: A Review. Seminars In Orthodontics, 2004.
Elsevier, 266-276.
De Coster, L. 2007. The Familial Line, Studied By A New Line Of
Reference. The European Journal Of Orthodontics, 29, I65-I67.
De Grauwe A, Ayaz I, Shujaat S, Dimitrov S, Gbadegbegnon L,

Vande Vannet B, Et Al. Cbct In Orthodontics: A Systematic Review 3d Imaging In Orthodontics: Part Ii. Journal Of Orthodontics, 31,
on Justification of CBCT In a Paediatric Population Prior To Orth- 154-162.
odontic Treatment. Eur J Orthod. 2019;41(4):381-9.
Halazonetis, D. J. 2001. Acquisition Of 3-Dimensional Shapes From
De Luca Canto, G., Pachêco-Pereira, C., Lagravere, M. O., Flores- Images. Am J Orthod Dentofacial Orthop, 119, 556-60.
Mir, C. & Major, P. W. 2015. Intra-Arch Dimensional Measurement
Hasanin M, Kaplan Sef, Hohlen B, Lai C, Nagshabandi R, Zhu X, Et
Validity Of Laser-Scanned Digital Dental Models Compared With
Al. Effects of Orthodontic Appliances on The Diagnostic Capability
The Original Plaster Models: A Systematic Review. Orthod Cranio-
of Magnetic Resonance Imaging in The Head and Neck Region: A
fac Res, 18, 65-76.
Systematic Review. Int Orthod. 2019;17(3):403-14.
Dindaroglu, F., Kutlu, P., Duran, G. S., Gorgulu, S. & Aslan, E.
Hayashi T, Arai Y, Chikui T, Hayashi-Sakai S, Honda K, Indo H, Et
2016. Accuracy And Reliability Of 3d Stereophotogrammetry: A
Al. Clinical Guidelines for Dental Cone-Beam Computed Tomog-
Comparison To Direct Anthropometry And 2d Photogrammetry.
raphy. Oral Radiology. 2018;34(2):89-104.
Angle Orthod, 86, 487-94.
Hutchinson, I. & Williams, P. 1999. Digital Cameras. Br J Orthod,
Drage, N. 2018. Cone Beam Computed Tomography In Orthodon-
26, 326-31.
tics. Orthodontic Update, 11, 27-30.
Isaacson, K. & Thom, A. R. 2015. Orthodontic Radiography Guide-
Elstrøm Uv, Muren Lp, Petersen Jb, Grau C. Evaluation of Image
lines. Am J Orthod Dentofacial Orthop, 147, 295-6.
Quality for Different Kv Cone-Beam Ct Acquisition and Recon-
struction Methods in The Head and Neck Region. Acta Oncologica Jacobs, S. G. 1999. Radiographic Localization Of Unerupted Maxil-
(Stockholm, Sweden). 2011;50(6):908-17. lary Anterior Teeth Using The Vertical Tube Shift Technique: The
History And Application Of The Method With Some Case Reports.
Ericson, S. & Kurol, P. J. 2000. Resorption Of Incisors After Ectopic
American Journal Of Orthodontics And Dentofacial Orthopedics,
Eruption Of Maxillary Canines: A Ct Study. Angle Orthod, 70,
116, 415-423.
415-23.
Juerchott A, Freudlsperger C, Weber D, Jende Jme, Saleem Ma,
Ferreira La, Grossmann E, Januzzi E, De Paula Mv, Carvalho Ac.
Zingler S, Et Al. In Vivo Comparison of Mri- And Cbct-Based 3d
Diagnosis Of Temporomandibular Joint Disorders: Indication
Cephalometric Analysis: Beginning of A Non-Ionizing Diagnos-
Of Imaging Exams. Brazilian Journal Of Otorhinolaryngology.
tic Era in Craniomaxillofacial Imaging? European Radiology.
2016;82(3):341-52.
2020;30(3):1488-97.
Fleming, P. S., Marinho, V. & Johal, A. 2011. Orthodontic Measure-
Karatas, O. H. & Toy, E. 2014. Three-Dimensional Imaging Tech-
ments On Digital Study Models Compared With Plaster Models: A
niques: A Literature Review. Eur J Dent, 8, 132-140.
Systematic Review. Orthod Craniofac Res, 14, 1-16.
Ko Hc, Liu W, Hou D, Torkan S, Spiekerman C, Huang Gj. Agree-
Forsyth, D. B., Shaw, W. C. & Richmond, S. 1996a. Digital Imaging
ment of Treatment Recommendations Based on Digital Vs Plaster
Of Cephalometric Radiography, Part 1: Advantages And Limita-
Dental Models. Am J Orthod Dentofacial Orthop. 2019;155(1):135-
tions Of Digital Imaging. Angle Orthod, 66, 37-42.
42.
Forsyth, D. B., Shaw, W. C., Richmond, S. & Roberts, C. T. 1996b.
Keim, R. G., Gottlieb, E. L., Nelson, A. H. & Vogels, D. S., 3rd 2008.
Digital Imaging Of Cephalometric Radiographs, Part 2: Image
2008 Jco Study Of Orthodontic Diagnosis And Treatment Proce-
Quality. Angle Orthod, 66, 43-50.
dures, Part 1: Results And Trends. J Clin Orthod, 42, 625-40.
Franco De Sá Gomes C, Libdy Mr, Normando D. Scan Time, Reli-
Kuijpers, M. A., Chiu, Y. T., Nada, R. M., Carels, C. E. & Fudalej,
ability and Accuracy of Craniofacial Measurements Using A 3d
P. S. 2014a. Three-Dimensional Imaging Methods For Quantita-
Light Scanner. Journal of Oral Biology and Craniofacial Research.
tive Analysis Of Facial Soft Tissues And Skeletal Morphology In
2019;9(4):331-5.
Patients With Orofacial Clefts: A Systematic Review. Plos One, 9,
Garayoa J, Castro P. A Study on Image Quality Provided by A Ki- E93442.
lovoltage Cone-Beam Computed Tomography. Journal of Applied
Kuijpers, M. A. R., Pazera, A., Admiraal, R. J., Berge, S. J., Vissink,
Clinical Medical Physics. 2013;14(1):3888.
A. & Pazera, P. 2014b. Incidental Findings On Cone Beam Com-
Graber, L. W., Vanarsdall, R. L., Vig, K. W. & Huang, G. J. 2016. puted Tomography Scans In Cleft Lip And Palate Patients. Clin
Orthodontics-E-Book: Current Principles And Techniques, Oral Investig, 18, 1237-1244.
Elsevier Health Sciences.Ghoneima A, Cho H, Farouk K, Kula K.
Luqmani S, Jones A, Andiappan M, Cobourne Mt. A Comparison
Accuracy And Reliability Of Landmark-Based, Surface-Based And
of Conventional Vs Automated Digital Peer Assessment Rat-
Voxel-Based 3d Cone-Beam Computed Tomography Superimposi-
ing Scoring Using the Carestream 3600 Scanner and Cs Model+
tion Methods. Orthod Craniofac Res. 2017;20(4):227-36.
Software System: A Randomized Controlled Trial. Am J Orthod
Gupta A, Kharbanda Op, Balachandran R, Sardana V, Kalra S, Dentofacial Orthop. 2020;157(2):148-55 E1.
Chaurasia S, Et Al. Precision of Manual Landmark Identification
Luu, N. S., Nikolcheva, L. G., Retrouvey, J. M., Flores-Mir, C.,
Between As-Received and Oriented Volume-Rendered Cone-Beam
El-Bialy, T., Carey, J. P. & Major, P. W. 2012. Linear Measurements
Computed Tomography Images. Am J Orthod Dentofacial Orthop.
Using Virtual Study Models. Angle Orthod, 82, 1098-106.
2017;151(1):118-31.
Martin, C. B., Chalmers, E. V., Mcintyre, G. T., Cochrane, H. &
Hajeer, M., Millett, D., Ayoub, A. & Siebert, J. 2004. Applications Of

Mossey, P. A. 2015. Orthodontic Scanners: What’s Available? J and dentofacial orthopedics, 129, 611-618.
Orthod, 42, 136-43.
COWARD, T. J., WATSON, R. M. & SCOTT, B. J. 1997. Laser scan-
Mcnamara, C., House, K., Davies, R., Barker, C. S., Chawla, O., ning for the identification of repeatable landmarks of the ears and
Sandy, J. R. & Ireland, A. J. 2011. The Current Status Of 3d Imaging face. Br J Plast Surg, 50, 308-14.
In Dental Practice. Dent Update, 38, 679-82, 684-6, 688-90.
DAHLLÖF, G. & HUGGARE, J. Orthodontic considerations in the
Merrett, S. J., Drage, N. A. & Durning, P. 2009. Cone Beam Com- pediatric cancer patient: a review. Seminars in orthodontics, 2004.
puted Tomography: A Useful Tool In Orthodontic Diagnosis And Elsevier, 266-276.
Treatment Planning. J Orthod, 36, 202-10.
DE COSTER, L. 2007. The familial line, studied by a new line of
Naoumova, J. & Lindman, R. 2009. A Comparison Of Manual reference. The European Journal of Orthodontics, 29, i65-i67.
Traced Images And Corresponding Scanned Radiographs Digitally
DE GRAUWE, A., AYAZ, I., SHUJAAT, S., DIMITROV, S., GBA-
Traced. Eur J Orthod, 31, 247-53.
DEGBEGNON, L., VANDE VANNET, B. & JACOBS, R. 2019.
Nute, S. J. & Moss, J. P. 2000. Three-Dimensional Facial Growth CBCT in orthodontics: a systematic review on justification of
Studied By Optical Surface Scanning. J Orthod, 27, 31-8. CBCT in a paediatric population prior to orthodontic treatment.
European journal of orthodontics, 41, 381-389.
Oenning Ac, Jacobs R, Pauwels R, Stratis A, Hedesiu M, Salmon
B, Et Al. Cone-Beam Ct In Paediatric Dentistry: Dimitra Project DE LUCA CANTO, G., PACHÊCO-PEREIRA, C., LAGRAVERE,
Position Statement. Pediatr Radiol. 2018;48(3):308-16.ABDUO, M. O., FLORES-MIR, C. & MAJOR, P. W. 2015. Intra-arch dimen-
J. & ELSEYOUFI, M. 2018. Accuracy of Intraoral Scanners: A sional measurement validity of laser-scanned digital dental models
Systematic Review of Influencing Factors. The European journal of compared with the original plaster models: a systematic review.
prosthodontics and restorative dentistry, 26, 101-121. Orthod Craniofac Res, 18, 65-76.
AHMAD, I. 2009. Digital dental photography. Part 2: Purposes and DE SÁ GOMES, C. F., LIBDY, M. R. & NORMANDO, D. 2019.
uses. Br Dent J, 206, 459-64. Scan time, reliability and accuracy of craniofacial measurements
using a 3D light scanner. Journal of oral biology and craniofacial
ARAGÓN, M. L., PONTES, L. F., BICHARA, L. M., FLORES-MIR,
research, 9, 331-335.
C. & NORMANDO, D. 2016. Validity and reliability of intraoral
scanners compared to conventional gypsum models measurements: DEVEREUX, L., MOLES, D., CUNNINGHAM, S. J. & MCK-
a systematic review. European journal of orthodontics, 38, 429-434. NIGHT, M. 2011. How important are lateral cephalometric radio-
graphs in orthodontic treatment planning? American Journal of
ARMSTRONG, C., JOHNSTON, C., BURDEN, D. & STEVEN-
Orthodontics and Dentofacial Orthopedics, 139, e175-e181.
SON, M. 2003. Localizing ectopic maxillary canines—horizontal
or vertical parallax? The European Journal of Orthodontics, 25, DINDAROGLU, F., KUTLU, P., DURAN, G. S., GORGULU, S. &
585-589. ASLAN, E. 2016. Accuracy and reliability of 3D stereophotogram-
metry: A comparison to direct anthropometry and 2D photogram-
BAUMRIND, S., KORN, E. L. & WEST, E. E. 1984. Prediction of
metry. Angle Orthod, 86, 487-94.
mandibular rotation: an empirical test of clinician performance.
American journal of orthodontics, 86, 371-385. DRAGE, N. 2018. Cone Beam Computed Tomography in Ortho-
dontics. Orthodontic Update, 11, 27-30.
BEAU, A., BOSSARD, D. & GEBEILE-CHAUTY, S. 2015. Magnetic
resonance imaging artefacts and fixed orthodontic attachments. DRAGE, N., ROGERS, S., GREENALL, C. & PLAYLE, R. 2013.
Eur J Orthod, 37, 105-10. Incidental findings on cone beam computed tomography in orth-
odontic patients. Journal of orthodontics, 40, 29-37.
BJÖRK, A. & SKIELLER, V. 1983. Normal and abnormal growth
of the mandible. A synthesis of longitudinal cephalometric implant ELSTRØM, U. V., MUREN, L. P., PETERSEN, J. B. & GRAU, C.
studies over a period of 25 years. The European Journal of Ortho- 2011. Evaluation of image quality for different kV cone-beam CT
dontics, 5, 1-46. acquisition and reconstruction methods in the head and neck
region. Acta Oncologica, 50, 908-917.
BOTTICELLI, S., VERNA, C., CATTANEO, P. M., HEIDMANN,
J. & MELSEN, B. 2011. Two-versus three-dimensional imaging in ERICSON S & KUROL J 1987, R. A. O. E. M. C., AJODO, 91 ;483-
subjects with unerupted maxillary canines. The European Journal 492.
of Orthodontics, 33, 344-349.
ERICSON, S. & KUROL, P. J. 2000. Resorption of incisors after
BRENNAN, J. 2002. An introduction to digital radiography in ectopic eruption of maxillary canines: a CT study. Angle Orthod,
dentistry. J Orthod, 29, 66-9. 70, 415-23.
CAMARDELLA, L. T., BREUNING, H. & DE VASCONCELLOS FLEMING, P. S., MARINHO, V. & JOHAL, A. 2011. Orthodontic
VILELLA, O. 2020. Testing for accuracy, reproducibility, and reli- measurements on digital study models compared with plaster mod-
ability. Journal of Orofacial Orthopedics/Fortschritte der Kieferor- els: a systematic review. Orthod Craniofac Res, 14, 1-16.
thopädie, 81, 153-156.
FORSYTH, D. B., SHAW, W. C. & RICHMOND, S. 1996a. Digital
CEVIDANES, L. H., STYNER, M. A. & PROFFIT, W. R. 2006. imaging of cephalometric radiography, Part 1: Advantages and
Image analysis and superimposition of 3-dimensional cone-beam limitations of digital imaging. Angle Orthod, 66, 37-42.
computed tomography models. American journal of orthodontics
FORSYTH, D. B., SHAW, W. C., RICHMOND, S. & ROBERTS, C.

T. 1996b. Digital imaging of cephalometric radiographs, Part 2: Im- techniques: A literature review. Eur J Dent, 8, 132-140.
age quality. Angle Orthod, 66, 43-50.
KEIM, R. G., GOTTLIEB, E. L., NELSON, A. H. & VOGELS, D. S.,
GALANTE, D. L. 2009. History and current use of clinical photog- 3RD 2008. 2008 JCO study of orthodontic diagnosis and treatment
raphy in orthodontics. J Calif Dent Assoc, 37, 173-4. procedures, part 1: results and trends. J Clin Orthod, 42, 625-40.
GARAYOA, J. & CASTRO, P. 2013. A study on image quality pro- KUIJPERS, M. A., CHIU, Y. T., NADA, R. M., CARELS, C. E. &
vided by a kilovoltage cone‐beam computed tomography. Journal FUDALEJ, P. S. 2014a. Three-dimensional imaging methods for
of Applied Clinical Medical Physics, 14, 239-257. quantitative analysis of facial soft tissues and skeletal morphology
in patients with orofacial clefts: a systematic review. PLoS One, 9,
GHONEIMA, A., CHO, H., FAROUK, K. & KULA, K. 2017.
e93442.
Accuracy and reliability of landmark-based, surface-based and
voxel-based 3D cone-beam computed tomography superimposi- KUIJPERS, M. A. R., PAZERA, A., ADMIRAAL, R. J., BERGE, S.
tion methods. Orthod Craniofac Res, 20, 227-236. J., VISSINK, A. & PAZERA, P. 2014b. Incidental findings on cone
beam computed tomography scans in cleft lip and palate patients.
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G.
Clin Oral Investig, 18, 1237-1244.
J. 2016. Orthodontics-e-book: current principles and techniques,
Elsevier Health Sciences. LOZANO, F. 2015. Overview of Dental Photography. Todays FDA,
27, 34-5, 37.
HAJEER, M., MILLETT, D., AYOUB, A. & SIEBERT, J. 2004.
Applications of 3D imaging in orthodontics: part II. Journal of LUQMANI, S., JONES, A., ANDIAPPAN, M. & COBOURNE, M.
orthodontics, 31, 154-162. T. 2020. A comparison of conventional vs automated digital Peer
Assessment Rating scoring using the Carestream 3600 scanner
HALAZONETIS, D. J. 2001. Acquisition of 3-dimensional shapes and CS Model+ software system: A randomized controlled trial.
from images. Am J Orthod Dentofacial Orthop, 119, 556-60. American Journal of Orthodontics and Dentofacial Orthopedics,
HAN, U. K., VIG, K. W., WEINTRAUB, J. A., VIG, P. S. & KOW- 157, 148-155. e1.
ALSKI, C. J. 1991. Consistency of orthodontic treatment decisions MÄNNCHEN, R. 2001. A critical evaluation of the pitchfork analy-
relative to diagnostic records. American Journal of Orthodontics sis. European journal of orthodontics, 23.
and Dentofacial Orthopedics, 100, 212-219.
MARTIN, C. B., CHALMERS, E. V., MCINTYRE, G. T., CO-
HUANG, G. J., ROLOFF-CHIANG, B., MILLS, B. E., SHAL- CHRANE, H. & MOSSEY, P. A. 2015. Orthodontic scanners: what’s
CHI, S., SPIEKERMAN, C., KORPAK, A. M., STARRETT, J. L., available? J Orthod, 42, 136-43.
GREENLEE, G. M., DRANGSHOLT, R. J. & MATUNAS, J. C.
2013. Effectiveness of MI Paste Plus and PreviDent fluoride varnish MCNAMARA, C., HOUSE, K., DAVIES, R., BARKER, C. S.,
for treatment of white spot lesions: a randomized controlled trial. CHAWLA, O., SANDY, J. R. & IRELAND, A. J. 2011. The current
American Journal of Orthodontics and Dentofacial Orthopedics, status of 3D imaging in dental practice. Dent Update, 38, 679-82,
143, 31-41. 684-6, 688-90.
HUTCHINSON, I. & WILLIAMS, P. 1999. Digital cameras. Br J MERRETT, S. J., DRAGE, N. A. & DURNING, P. 2009. Cone beam
Orthod, 26, 326-31. computed tomography: a useful tool in orthodontic diagnosis and
treatment planning. J Orthod, 36, 202-10.
IRELAND, A. J., MCNAMARA, C., CLOVER, M., HOUSE, K.,
WENGER, N., BARBOUR, M. E., ALEMZADEH, K., ZHANG, L. NAOUMOVA, J. & LINDMAN, R. 2009. A comparison of manual
& SANDY, J. R. 2008. 3D surface imaging in dentistry–what we are traced images and corresponding scanned radiographs digitally
looking at. British dental journal, 205, 387-392. traced. Eur J Orthod, 31, 247-53.
ISAACSON, K. & THOM, A. R. 2015. Orthodontic radiography NUTE, S. J. & MOSS, J. P. 2000. Three-dimensional facial growth
guidelines. Am J Orthod Dentofacial Orthop, 147, 295-6. studied by optical surface scanning. J Orthod, 27, 31-8.
JACOBS, S. G. 1999. Radiographic localization of unerupted POLAT-OZSOY, O., GOKCELIK, A. & TOYGAR MEMIKOGLU,
maxillary anterior teeth using the vertical tube shift technique: T. U. 2009. Differences in cephalometric measurements: a com-
the history and application of the method with some case reports. parison of digital versus hand-tracing methods. Eur J Orthod, 31,
American journal of orthodontics and dentofacial orthopedics, 254-9.
116, 415-423. QUINTERO, J. C., TROSIEN, A., HATCHER, D. & KAPILA, S.
JUERCHOTT, A., FREUDLSPERGER, C., WEBER, D., JENDE, J. 1999. Craniofacial imaging in orthodontics: historical perspec-
M., SALEEM, M. A., ZINGLER, S., LUX, C. J., BENDSZUS, M., tive, current status, and future developments. Angle Orthod, 69,
HEILAND, S. & HILGENFELD, T. 2020. In vivo comparison of 491-506.
MRI-and CBCT-based 3D cephalometric analysis: beginning of a RISCHEN, R. J., BREUNING, K. H., BRONKHORST, E. M. &
non-ionizing diagnostic era in craniomaxillofacial imaging? Euro- KUIJPERS-JAGTMAN, A. M. 2013. Records needed for orthodon-
pean Radiology, 30, 1488-1497. tic diagnosis and treatment planning: a systematic review. PloS one,
KALPANA, D., RAO, S., JOSEPH, J. & KURAPATI, S. 2018. Digital 8, e74186-e74186.
dental photography. Indian Journal of Dental Research, 29, 507. SANDLER, J. & MURRAY, A. 2001. Digital photography in ortho-
KARATAS, O. H. & TOY, E. 2014. Three-dimensional imaging dontics. J Orthod, 28, 197-201.

SANDLER, P. J., MURRAY, A. M. & BEARN, D. 2002. Digital
records in orthodontics. Dent Update, 29, 18-24.
SANTORO, M., JARJOURA, K. & CANGIALOSI, T. J. 2006. Accu-
racy of digital and analogue cephalometric measurements assessed
with the sandwich technique. Am J Orthod Dentofacial Orthop,
129, 345-51.
SHARMA, S., WORMALD, J. C. R., FISHMAN, J. M., ANDREWS,
P. & KOTECHA, B. T. 2019. Rhinological interventions for obstruc-
tive sleep apnoea - a systematic review and descriptive meta-analy-
sis. J Laryngol Otol, 133, 168-176.
SIGNORELLI, L., PATCAS, R., PELTOMÄKI, T. & SCHÄTZLE,
M. 2016. Radiation dose of cone-beam computed tomography
compared to conventional radiographs in orthodontics. Journal of
Orofacial Orthopedics/Fortschritte der Kieferorthopädie, 77, 9-15.
SREEVATSAN, R., PHILIP, K., PETER, E., SINGH, K. V. &
GAHLOT, M. S. Digital Photography in General and Clinical
Dentistry-Technical Aspects and Accessories. 2015.
THORNE, M. 1992. ICRP publication 60: 1990 recommendations
of the international commission on radiological protection: Annals
of the ICRP, 21 (1–3), 1991. Pergamon.
WALKER, L., ENCISO, R. & MAH, J. 2005. Three-dimensional
localization of maxillary canines with cone-beam computed
tomography. American Journal of Orthodontics and Dentofacial
Orthopedics, 128, 418-423.
YI, J., XIAO, J., LI, Y., LI, X. & ZHAO, Z. 2017. Efficacy of piezoci-
sion on accelerating orthodontic tooth movement: A systematic
review. Angle Orthod, 87, 491-498.
ZHYLICH, D., KRISHNAN, P., MUTHUSAMI, P., RAYNER, T.,
SHROFF, M., DORIA, A., TOMPSON, B., LOU, W. & SURI, S.
2017. Effects of orthodontic appliances on the diagnostic quality
of magnetic resonance images of the head. American Journal of
Orthodontics and Dentofacial Orthopedics, 151, 484-499.

3
Cephalometric In
Orthodontics
Written by: Mohammed Almuzian, Haris Khan, Syed A. A. Bukhari, Aroosh Ahmed, Khaula Ashfaq
In this Chapter
1. History
2. Equipments
3. Clinical stages in taking a cephalogram
4. Uses of cephalometry
5. Requirements of cephalometric measurement
6. Common cephalometric landmarks
7. Cephalometric lines for skeletal analysis
8. Cephalometric lines for dental analysis
9. Cephalometric measurement for profile analysis
10. Cephalometric analysis techniques
11. Key cephalometric analysis
12. EXAM NIGHT REVIEW
T he term cephalometric came from Latin meaning ‘mea-
ing the head to tip down) and respiratory pattern (in order
to increase airway patency patients may tip their head up).
surement of the head’. The conventional meaning of cepha- There are two methods of attaining NHP:
lometric is ‘using a standardised skull radiograph to assess
facial, dental, skeletal relationships and airway analysis. 1. Crude method: Patient is relaxed and looks at a distant
Cephalometric is a 2 dimensional image of a 3 dimensional object on the horizon.
object. Cephalometric evaluation is integral to orthodontics 2. Sensory method: Patient looks at their own eyes in a
and used for assessment, diagnosis and treatment planning mirror, and moves their head up and down in increas-
of the orthodontic patient. ingly smaller movements until they feel they are in a
History comfortable position.
Cephalometric machine was developed in the 1930’s by Sometimes the Frankfort plane is used to help orientate the
Broadbent (USA) and Hofrath (Germany) and used for patient in NHP, by keeping the Frankfort plane parallel to
growth studies (Broadbent, 1937). Originally postero-ante- the floor. However, the Frankfort plane is an anatomical
rior and lateral views were recommended to allow 3-dimen- position and therefore might not be reproducible for the
sional assessment (Broadbent, 1937). patient.
Equipments Uses of cephalometry
These include: These include:
• Cephalostat or craniostat: It is used to position the 1. Diagnosis and treatment planning including:
patient’s head in the machine, hence, it is a stabilizing • Assessment of sagittal and vertical skeletal relation-
apparatus with ear rods. It also contains the cassette ships.
holder and film.
• Assessment of incisor inclination and position.
• Cassette: It usually contains rare earth intensifying
• Assessment of soft tissue profile.
screens and indirect action film. The dimension is usu-
ally 18 x 24 cm. It is placed 45 to 55 cm (1.5 to 1.8 feet) • Orthognathic surgery planning and VTO (visual
behind the mid-sagittal plane of the patient. The greater treatment objectives).
the distance from the mid-sagittal plane, the greater the
• Helping in detection and localization of unerupted
magnification error.
teeth or pathology.
• X-ray generating apparatus: The x-ray source is in a
2. During active treatment including:
fixed position relative to the cephalostat and the film.
Therefore, successive radiographs are standardized and • Assessment of skeletal and dental relationships post-
can be compared by superimpostion without magnifi- functional therapy.
cation error. The x-ray source should be 120-150cm (5
• Assessment of incisor position, to plan mechanics of
feet) away from the mid-sagittal plane of the patient.
space closure and anchorage demands.
Collimation of the x-rays occurs through the use of a
triangular collimator. This limits exposure to the pa- • In orthognathic surgery cases for surgical planning,
tient’s cranial base and facial skeleton. as well as post-operatively to assess surgical changes.
• Aluminum wedge filter: It has a specific design in 3. End of treatment including:
order to attenuate the x-ray beam selectively in the • Assessment of dental arch relationship.
soft tissue region. The wedge filter enhances soft tissue
visibility on the film. The wedge filter is either attached • Planning retention according to treatment changes.
to the tube head or the cepalostat, hence, positioned • Baseline records to monitor changes in post-reten-
between the patient and the anterior part of the cassette. tion phase (Björk, 1954).
Clinical stages in taking a cephalogram • Determining the reasons for relapse and unfavour-
The patient is positioned in the cephalostat in natural head able growth, especially in orthognathic surgery cas-
position (NHP). NHP is a physiological and reproduc- es.
ible position, in which the patient usually positions their 4. Research purposes (Bjork and Palling, 1955, Bjork, 1955)
head. NHP can be reproduced within 1 or 2 degrees. NHP
is affected by audio-visual reflex, skeletal pattern (in Class Is lateral cephalometry essential for treatment planning?
II cases the patients may tip their head up), growth pattern This is a very debatable topic in which the clinician skills
(posterior rotation can result in the mandible flexing caus-
32 Cephalometric In Orthodontics
and philosophy have significant impact. Generally, the use of • Menton (Me): The most inferior point of the mandibu-
cephalograms depends on the clinician’s experience, prefer- lar symphysis in the midline, while soft tissue Menton
ences and the severity of cases. (Me’) is the lowest point on the contour of the soft tissue
chin.
It was concluded in one study that only 4-20 % of treatment
plans could have changed in the presence of cephalometric • Gonion (Go): The most posterior and inferior point on
analysis (Bruks et al., 1999). Another study showed that the angle of the mandible.
cephalometric analysis is not an essential requirement for
• Pogonion (Pog): The most anterior point on the bony
orthodontic treatment planning, as it did not influence treat-
chin, while soft tissue Pogonion (Pog’) is the most
ment planning decisions for patients with Class II malocclu-
prominent point on the soft tissue chin.
sions (Nijkamp et al., 2008).
• Point A (subspinale): This is the deepest point on the
Requirements of cephalometric measurement
curved contour of the bony maxilla between the ante-
These include: rior nasal spine and alveolar crest.
• Reliable. • Point B (supramentale): This is the deepest point on the
curved contour of the mandible between the chin and
• Reproducible.
alveolar crest.
• Accurate.
• Molar superioris (Ms): The mesial cusp tip of the upper
• Easy. first molar.
• Accessible and cheap. • Molar inferioris (Mi): The mesial cusp tip of the lower
first molar.
• Use of stable reference points.
• Incisor superius (Is): Tip of the crown of the most ante-
• Not be affected by patient size or age.
rior upper central incisor.
Common cephalometric landmarks
• Upper incisor apex (Banerjee et al.): The root apex of
These include: the most anterior upper central incisor.
• Sella (S): Midpoint of the sella turcica (pituitary fossa). • Incisor inferius (Guyer et al.): Tip of the crown of the
• Porion (Po): Most posterior and superior point on the most anterior lower central incisor.
external auditory meatus. • Lower incisor apex (LIA): The root apex of the most
• Condylion (Cd): The most posterior and superior point anterior lower central incisor.
on the mandibular condyle. • Glabella (G): Mid-brow area, and taken as the most
• Nasion (N): The most anterior point on the frontonasal prominent point on the forehead in the mid-sagittal
suture in the midline, while soft tissue Nasion (Van plane.
Leeuwen et al.) is the most prominent point on the soft • Pronasale (P): The most prominent anterior part of the
tissue in front of Nasion point. nose tip.
• Anterior nasal spine (ANS): The tip of the anterior nasal • Subnasale (Sn): Junction between the beginning of the
spine in the midline. upper lip and lower border of the nose in the mid-
• Posterior nasal spine (PNS): The tip of the posterior sagittal plane.
nasal spine in the midline. • Labrale superius (LS): The most prominent point on
• Articulare point (Ar): Point on intersection of poste- the maximum convexity of the vermillion border of the
rior cranial base and posterior border of the ascending upper lip in the mid-sagittal plane.
ramus. • Labrale inferius (LI): The most prominent point at the
• Basion (Ba): The most anterior inferior point of the maximum convexity of the vermillion border of the
foramen magnum. lower lip in the mid-sagittal plane.
• Orbitale (Or): The most inferior and anterior point on Cephalometric lines for skeletal analysis
the orbital margin. These include:
• Gnathion (Gn): The most anterior and inferior point on • Frankfort horizontal line / plane: A line constructed
the bony chin. from porion to orbitale. Another way to construct the
Frankfort line is simply to draw it at a specific inclina-
Cephalometric In Orthodontics 33
tion to SN, usually 6 degrees. The inclination of SN to point of the overlap of the mesio-buccal cusps of the
the true horizontal plane (or to the Frankfort plane first molars and the buccal cusps of the premolars or
if true horizontal plane is not known) should always deciduous molars. It is used by Ricketts (Ricketts, 1960,
be noted, and if the inclination of SN is more than 8 Ricketts, 1961) and in the Wits analysis (Jacobson,
degrees, any measurements based on SN should be 1975).
corrected by this difference. The drawbacks in using of
• Bisecting occlusal plane/ line: A line joining the mid-
Frankfort horizontal line include that both porion and
point of the overlap of the mesio-buccal cusps of the
orbitale are bilateral structures which frequently do not
upper and lower first molars with the point bisecting
coincide and therefore have to be averaged. They are
the overbite of the incisors. It is used by Downs (Downs,
also difficult to locate in some cases.
1948, Downs, 1952) and Steiner (Steiner, 1953).
• Sella-nasion line / plane: The line is constructed from
Cephalometric measurements for profile analysis
sella to nasion, and represents the anterior cranial base.
The benefits of Sella-Nasion line are the ease to locate These include:
both Sella and Nasion points lie in the midsagittal
• Soft tissue Nasion to Frankfort horizontal plane: By
plane. Sella-nasion line is useful in assessing the vertical
using this technique a vertical line is drawn from soft
jaw relationship, correction of the Frankfurt plane, in
tissue Nasion perpendicular to Frankfort horizontal.
evaluating the inclination of upper incisors to the cra-
Subnasale or soft tissue point A should be approxi-
nial base and it can be used as a stable reference point
mately 2-3 mm in front of this line, and the soft tissue
on the cranial base for superimposition. The weaknesses
Pogonion should lie 2 mm behind this facial plane.
of Sella-Nasion line include that the Sella point can alter
during early growth and that the Nasion can be sub- • Facial vertical or Meridian line was developed by
jected to both horizontal and vertical growth changes/ Gonzales-Ulloa (Gonzalez-Ulloa, 1962, González-Ulloa
variations. and Stevens, 1968), by dropping a line from soft tissue
Nasion, perpendicular to true horizontal line with the
• Maxillary line / plane: It is a line connecting the anterior
patient in natural head position. Subnasale should lie on
nasal spine and the posterior nasal spine. The Maxillary
this line while soft tissue pogonion should be 0 ± 2 mm
line is used to assess the relationship between Maxilla to
to this line.
Frankfort plane, to SN plane, to mandible as well as the
inclination of upper incisors to the maxillary skeletal • Bass aesthetic analysis (Bass, 2003): In this analysis a
base. The line can be used for maxillary superimposi- perpendicular line is dropped from Subnasale with the
tion. patient in NHP.
• Mandibular line / plane: It can be constructed (a) as a • Z angle (Merrifield, 1966): It is formed by the intersec-
line tangent to the lower border of the mandible and tion of the tangent to the chin and vermilion border of
Menton, as described by Tweed (Tweed, 1946, Tweed, most prominent lip and Frankfurt horizontal, normal
1954), Wylie (Wylie, 1947) and Ricketts (Ricketts, 1960, value range is at 80˚+9˚. It is also called the “Profile line
Ricketts, 1961). Other described it as a line connecting of Merrifield”.
Gonion to Gnathion, as described by Steiner (Steiner, • Profile angle is the angle of convexity as described by
1953) or as as a line connecting Gonion to Menton, as Burstone. This angle formed between a line from soft
described in the Eastman analysis (Mills, 1970). tissue glabella to subnasale, and from subnasale to soft
• The Mandibular line is used to assess the relationship tissue pogonion. It represents the total facial angle and
between vertical jaw relationship, mandibular to Frank- range from 165˚ -175˚.
fort plane, to SN plane, to maxillary line as well as the • Powell analysis involves a combination of nasofrontal
inclination of lower incisors to mandibular plane. It can angle, nasofacial angle, nasomental angle, and mento-
be also used for mandibular superimposition. cervical angle. It has been developed to give insight into
Cephalometric lines for dental analysis an ideal facial profile.
These include: Cephalometric measurements for lip analysis
• Anatomical occlusal plane connecting the tip of lower These include:
incisor edges to the midpoint between the upper and • Esthetic line (E-line) (Ricketts): It connects the nasal tip
lower first permanent molar cusps. It is used in the (pronasale) to soft tissue pogonion. In adults, the upper
Bjork analysis (Bjork, 1947, Björk, 1954). lip should be 4mm behind this line while the lower lip
• Functional occlusal plane is the line joining the mid- should be 2 mm behind this line. The assessment of
lips using the E line is dependent on the nose and chin
projection. 2. Designed for treatment planning such as Ballard con-
version technique
• Steiner line (S-line): It connects soft tissue pogonion to
the midpoint between subnasale and the nasal tip. The 3. Analysis of change in growth and treatment such as
lips should touch this line.
• Pancherz technique
• Harmony line (H-angle): The H-angle is formed by a
• Pitchfork technique
line tangent to the chin and upper lip with the NB line.
Holdaway stated that in balanaced, H-angle should be • Bolton (Template analysis)
within the range of 7° to 15°, which is dictated by the
4. Research purposes such as Bjork technique
patient’s skeletal convex¬ity. The ideal position of the
lower lip to the H line is 0 to 0.5 mm anterior. Ideally Key cephalometric analysis
this line should bisect the nose. 1. Sagittal analysis such as:
Cephalometric measurement for labionasal analysis • SNA: The anteroposterior position of the maxilla is as-
Nasolabial angle (NLA) is formed between the nasal colu- sessed by measuring the angle formed between the lines
mella and the upper lip. The average value is 90˚–110˚. It SN and NA.
can be divided by true horizontal at subnasale point into • SNB: The anteroposterior position of the mandible is as-
two angles (upper one represents the nasal angulation of an sessed by measuring the angle formed between the lines
average 28˚, and the lower angle represents the upper lip SN and NB.
angulation of average 85 ˚). NLA depends on:
• ANB: The difference between SNA and SNB angles de-
• Anteroposterior position of upper incisors. fines the anteroposterior relationship between the max-
• Anteroposterior position of the maxilla. illa and mandible.
• The morphology of the upper lip. • However, it is important to notice that both points A and
B do not represent the true anterior extent of the skeletal
• The vertical position of the nasal tip.
bases.
• Columella position and orientation.
Factors affecting the ANB angle
Cephalometric measurement for labio-mental analysis
These include:
Labiomental angle is the angle formed between the lines
• Cranial base length.
from lower lip to soft tissue B point, and soft tissue B point
to soft tissue Menton. It is influenced by the incisor inclina- • Cranial base orientation.
tion and anterior lower face height. The average value is • A and B points can be changed due to bone remodelling
110–130 degree. Excessively proclined lower incisor teeth, that occurs during the orthodontic movement of the
a prominent chin and a reduced lower anterior facial height upper and lower incisor teeth.
may lead to an acute labiomental angle.
• Jaw orientation.
Cephalometric analysis techniques
• Facial height.
They can be classified into analysis that:
Ballard cephalometric analysis
1. Solely describe disharmony such as
This analysis is used to assess the anteroposterior jaw posi-
• Down’s technique tion through measuring the cephalometric overjet (Ballard,
• Steiner technique 1951). The inclination of the incisors is decompensated to
the normal values, and then the overjet is measured. The
• Ricketts technique
normal value of the upper incisor to the maxillary plane is
• Harvold technique 109˚, and the lower incisor to the mandibular plane is 93˚.
But for Ballard conversion, the value of the lower incisors is
• McNamara technique
calculated by subtracting the maxillary–mandibular plane
• Sassouni technique angle (MMPA) from 120°. In order to perform Ballard
conversion: (a) Trace on a separate piece of tracing paper the
• Wits technique
outline of the maxilla, the mandibular symphysis, the inci-
• Wylie technique sors and the maxillary and mandibular planes, (b) mark the
‘rotation points’ of the incisors one-third of the root length
• Tweed technique
away from the root apex, (c) by rotating around the point
marked, reposition the upper incisor at an angle of 109° to onto the functional occlusal plane (AO and BO), where the
the maxillary plane and repeat the same for the lower inci- horizontal difference between these points is subsequently
sor taking in consideration the adjusted value based on the measured. The Wits analysis is influenced by tooth position
MMPA value. and movement as point A and B are subject to remodelling
depending on incisor position. This can affect the horizonal
Interpretations of Ballard conversion
and vertical position of A and B points. The weakness of
These include: the Wits appraisal is the difficulty to construct the occlusal
plane which significantly affect the outcome measurement.
• Mild skeletal 2: Lower incisors occlude behind the
If there is a clockwise rotation of the occlusal plane, AO will
cingulum plateau but not posterior to the upper incisor
be behind BO. If there is a counter clockwise rotation of the
tooth.
occlusal plane, BO will be ahead of AO, and not represent
• Severe skeletal 2: Lower incisors occlude behind the cin- the anteroposterior discrepancy. Some important points of
gulum plateau and posterior to the upper incisor tooth. the Wits appraisal is given in table 1.
• Mild skeletal 3: Lower incisors occlude anterior to up- Table1: Wits analysis Jacobson (1975)
per cingulum plateau and positive overjet.
Males BO should lie 1mm ahead
• Severe skeletal 3: Lower incisors occlude anterior to up-
of AO
per cingulum plateau and reverse overjet.
Females AO should coincide with
Weaknesses of Ballard conversion BO
It relies on the basis that upper and lower incisors have an Skeletal Class II malocclu- AO should lie ahead of BO
average inclination to the cranial base. It also relies on the sion
fact that the centre of resistance being one third from the Skeletal Class III malocclu- BO lies ahead of AO
apex, and incisors rotate around this point, which is not true sion
in all cases
Harvold Analysis
Sassouni analysis
It describes the severity and degree of jaw disharmony by
This analysis uses five horizontal anatomic planes: measuring the unit lengths of the mandible (Condylion-
• The inclination of the anterior cranial base. Pog) and the maxilla (Condylion-ANS), and comparing the
difference between them (Table 2) (Harvold, 1974). The dif-
• Frankfort plane. ference between these numbers provides an indication of the
• Palatal plane. size discrepancy between the jaws. The vertical assessment is
made via ANS-Me. It must be kept in mind that the shorter
• Occlusal plane.
the vertical distance between the maxilla and mandible, the
• Mandibular plane. more anteriorly the chin will be placed for any given unit
difference, and vice versa
Sassouni evaluated the anteroposterior position of the face
and dentition by using the above planes and constructing Downs analysis
various arcs intersecting them.
It is one of the earliest analyses which comprised of both
Interpretation of Sassouni analysis skeletal and dental components in the presence of normal
occlusion .Frankfort plane is used as a reference. Downs
These include:
study (Downs, 1948, Downs, 1952, Downs, 1956) was based
• Well-proportioned faces: The planes converge towards a on 20 Caucasian boys and girls, aged 12-17 years with excel-
single point and the anterior nasal spine, the maxillary lent facial and occlusal balance (Table 3 & 4).
incisor, and the bony chin should be located along the
same arc.
• Short face: If the planes intersect posterior to the occipi-
tal bone it means the patient has a short face / skeletal
deep bite).
Wits analysis by Jacobson The Wits analysis was conceived
primarily as a way to overcome the limitations of ANB as
an indicator of jaw discrepancy. (Jacobson, 1975, Jacobson,
1976). It is based on the vertical projection of points A and B
Table 2: Harvold Analysis
Variables Purpose Male Female
Maxillary length Measure the distance from the anterior bor- Mean values with age Mean values with age
der of the mandibular condyle to the anterior
nasal spine Age mm Age mm
6 82 6 80
9 87 9 85
12 92 12 90
14 96 14 92
16 100 16 93
Mandibular length Measure the distance from the same point to Age mm Age mm
the anterior point of the chin (Pog)
6 99 6 97
9 107 9 105
12 114 12 113
14 121 14 117
16 127 16 119
Lower face height Measure the distance from the Anterior nasal Age mm Age mm
spine to Menton
6 59 6 57
9 62 9 60
12 64 12 62
14 68 14 64
16 71 16 65
Table 3: Downs analysis skeletal component
Skeletal compo- Description Range

nent
1 Facial angle Angle formed between the Facial plane (N- 87.8 ° Measures the degree of protusion or
Pog) and Frankfort plane (±3.6) retrusion of the chin
2 Angle of convexity Angle formed between the lines Nasion to 0° Measures maxillary protusion in relation
point A & point A to Pogonion (±5.09) to the total profile.
3 A-B plane Angle formed between the Facial plane (N- -4.6° Measures the anterior limit of the denti-
Pog) & Point A to Point B (±3.67) tion in relation to facial profile
4 FMPA Angle between Frankfort plane and man- 21.9° Measures the vertical growth. If the
dibular plane (±3.24) angle increases that means the person is
a vertical grower as the mandible shifts
downward.
5 Y axis Angle formed between line extending from 59.4° Measures the direction of facial growth. If
S-Gn and the Frankfort plane (±3.82) angle is increasing (Class III) that means
the greater vertical growth of mandible
Check this – is it not the angle between SN
and if angle is decreasing (Class II) that
and S-D point in the middle of the symphy-
means greater horizontal growth of
sis?
mandible
Table 4. Downs analysis dental component
Dental component Description Range

1 Cant of occlusal plane to Angle formed between the occlusal plane and 9.3° Measures the slope of oc-
Frankfort plane Frankfort plane (±8.3) clusal plane
2 Interincisal angle Angle formed by a line passing through the incisal 135.4° This angle is decreased in
edge and the apex of the root of the upper and (±5.76) Class I bimaxillary pro-
lower central incisors trusion and Class II Div
1 cases and increased in
Class II Div 2 cases
3 Lower incisor-occlusal plane Angle formed between the long axis of the lower 14.5° Increased angle tells us
central incisor and the occlusal plane need to (±3.48) that the lower incisor is
elaborate on this angle. This is not clear proclined
4 Lower incisor-mandibular Angle formed between the long axis of the lower 1.4° Tells us about the procli-
plane central incisor and the mandibular plane need to (±3.78) nation or retroclination
elaborate on this angle. This is not clear of the lower incisors
5 Upper incisor to A-Pog Linear measurement. Line drawn from A-Pog and 2.7mm Tells us about the procli-
the distance from labial surface of upper incisor (±1.8) nation or retroclination
measured to this line need to elaborate on the of the upper incisors
constructed line. This is not clear
Downs analysis can be easily presented by plotting the
and / or superior the position of nasion, the lower the SNA
results on a two-polygon graph or wiggleogram, in which
angle. The more posterior and / or inferior the position of
one displayed the skeletal pattern and the other the dental
the nasion, the greater the SNA angle. Mills therefore intro-
pattern. The main advantage of a Wiggleogram is that it is a
duced a correction for this problem:
rapid quantitative and qualitative analysis. The centre of the
graph showed the average values of each pattern, while the • For every degree SNA is greater than 81, subtract 0.5
lateral part showed the extreme values. from the original ANB value.
Eastman analysis (Mills, 1982) • For every degree SNA is less than 81, add 0.5 from the
original ANB value.
Eastman analysis variables and norms are:
The vertical position of Sella does not alter the ANB as it
AP variables including:
affects the SNA and SNB angle to the same extent. To apply
• SNA: 81 (± 3)°. Eastman correction, SN-maxillary plane angle should be 8°±
3°.
• SNB: 78 (± 3) °.
Limitations of the Eastman correction
• ANB: (3 ± 2°) + Mills correction.
These include overestimation of the correction of ANB
Vertical variables including:
values when N is posterior. As N moved anteriorly, the East-
• SN-MxP= 8 (± 3)°. man correction overestimated the Class III skeletal relation-
ship (Kamaluddin et al., 2012).
• MMPA= 27 (± 5)°.
• FMPA 27= (± 5)°.
Steiner analysis
Dental variables including:
Steiner analysis was proposed by Cecil Steiner (Steiner,
• SN-UI = SNA.
1953). The SN plane (from Sella to Nasion) is used as a
• UI-MxP= 109 (± 6)°. horizontal reference plane. SN plane is used as both S and
• LI-MP= 93 (± 6)°. N can be easily located on the cephalometric radiograph
because these points are located in the mid sagittal plane of
Mills’ Eastman correction (Mills, 1970) the cranium. The skeletal and dental analysis of the Steiner
When relating the maxilla and mandible to the cranial base, analysis are shown in table 5.
any deviation in the cranial base could affect the jaw rela- Table 5. Steiner analysis
tionship and the ANB angle, for example: the more anterior
Skeletal analysis the mandible to cranial base is assessed using a vertical
line extending downward from Nasion perpendicular to
SNA 82° the Frankfort plane. The mandible (point Pog) should
SNB 80° be slightly back of this line (–2 to –4 mm).
ANB 2° • Anteroposterior skeletal base relationships unit mea-
SN-Mandibular plane 32° surements including: maxilla length unit measured
Condyle to E point 25° ±4 from Co–A point, mandibular length unit measured
from Co–Gn and the difference between these numbers
Pog-L point 66° ±4
provides an indication of the size discrepancy between
SN-Occlusal line 14.5° the skeletal bases.
Dental analysis • Vertical skeletal assessment including lower face height
Upper first molar to NA 27mm (ANS-Me), FMPA (Adults 22° while mixed dentition
IMPA 93° 25°)and facial axis (90°).
Inter incisal angle 130° • Dental relationships including upper incisor (the facial
Lower first molar to NB 23 mm surface of the upper incisor is assessed relative to a per-
pendicular line through point A, the average is 4-6mm)
U.I-NA distance 4mm
and lower incisor (the facial surface of the lower incisor
U.I-NA angle 22° is assessed relative to the A-Pogonion line, as in the
L.I-NB distance 4mm Ricketts analysis).
L.I-NB angle 25° • Airway space including upper pharyngeal width (<5
Steiner also pointed out acceptable compromises in ANB mm) and lower pharyngeal width (10–12 mm).
angle which he called Steiner sticks or chevrons. Tweed analysis
Limitations of Steiner analysis It was introduced by C. H. Tweed in 1946. It establishes the
These include (Abdullah et al., 2006): prognosis of treatment on the basis of the Tweed triangle,
which is formed by the FMPA and lower incisor axis planes
• It is difficult to rely on the ANB angle as it is influenced (Tweed, 1946, Tweed, 1954). A Frankfort mandibular inci-
by the vertical height of the face. If the vertical distances sor angle (FMIA) of 65-70° is considered ideal for good
between Nasion and points A and B increased, the ANB aesthetic outcomes. The lower incisor angle is adjusted to
angle decrease and vice versa. achieve the ideal FMIA and treatment is planned to achieve
• If the anteroposterior position of Nasion is abnormal, it this. The analysis has been used as a total analysis by some,
will change ANB value. One of the reasons for the birth even though Tweed stressed it was intended only as a treat-
of Wits analysis was to overcome this drawback. ment aid. The validity of the total analysis of Tweed triangle
has not been proven.
Ricketts analysis
2. Bjork analysis
It is a profile orientated analysis. It includes an aesthetic
plane and other variables similar to Downs’ analysis (Rick- This analysis involves over 90 measurements and it is re-
etts, 1960, Ricketts, 1961) . search orientated (Bjork, 1947, Björk, 1954). The analysis is
based on the polygon N-S-Ar-Go-Gn using the three angles:
McNamara analysis Saddle angle (N-S-Ar), Articular angle (S-Ar-Go) and Go-
The McNamara analysis combines elements of previous nial angle (Ar-Go-Gn), and the linear measurements of the
analyses (Ricketts and Harvold). Both Frankfort plane and sides of the polygon. The analysis also assesses the anterior
Basion-Nasion lines are used as reference planes (McNama- and posterior face height relationship ratio (PFH : AFH).
ra, 1984). This analysis evaluates the position of the denti- 3. Bolton template analysis
tion and jaws relative to each other, and to the cranial base.
The McNamara analysis includes: The templates exist in two forms:
• Anteroposterior skeletal base relationships relative • Schematic templates: showing the changing position of
to the cranial base: The relationship of the maxilla to selected landmarks with age on a single template.
cranial base can be assessed a vertical line extend- • Anatomical complete templates:This is particularly con-
ing downwards from Nasion, perpendicular to the venient for direct visual comparison of a patient with
Frankfort plane. The maxilla (point A) should be on or the reference group, whilst accounting for age.
slightly ahead of this line (0-1 mm). The relationship of
4. Pi analysis (Kumar et al., 2012) Exam Night Review
The Pi analysis has been introduced as a new method to CEPHALOMETRICS
assess the AP jaw relationship. It consists of two variables:
• Term cephalometric comes from Latin and the literally
the Pi angle and the Pi linear measurement. It utilizes the
meaning ‘measurement of head’
skeletal landmarks G and M points to represent the mandi-
ble and maxilla respectively. The advantage of these points is • Cephalometrics ( branch of orthodontics) used for
they are not affected by local remodelling secondary to den- assessment, diagnosis and treatment planning of the
tal movements, unlike points A and B. The reference plane orthodontic patient.
utilized in measuring the Pi analysis is the true horizontal,
• Developed in 1930’s by Broadbent (USA) and Hofrath
a line perpendicular to the true vertical obtained in natural
(Germany)
head position (NHP). The mean values for the Pi angle are:
Equipment
• Skeletal Class I: 3.40 (+2.04).
• Cephalostat or craniostat
• Skeletal Class II: 8.94 (+3.16).
• Cassette
• Skeletal Class III: 23.57 (+1.61).
• X-raapparatus
5. Pancherz analysis (Pancherz, 1982)
• Aluminum wedge filter
This analysis measures skeletal and dental treatment changes
of the mandible and maxilla by measuring linear changes Clinical stages in taking a cephalogram.
from a perpendicular plane at Sella to the occlusal line with Patient is positioned in the cephalostat in natural head posi-
radiographs superimposed on the SN plane. The weakness tion (NHP).
of this method is that it depends on maxillary structures and
the occlusal plane (OP), which are subject to change with NHP is a physiological and reproducible within 1 or 2 de-
dento-alveolar movements. grees. There are two methods of attaining NHP:
6. Pitchfork analysis (Johnston, 1996) • Crude: Patient is relaxed and looks at a distant object
in the horizon.
This analysis involves superimposition of 2 or more lateral
cephalograms to measure dental and skeletal changes rela- • Sensory: Patient looks at their own eyes in a mirror
tive to the functional occlusal plane (OP). Dental changes NHP is affected by:
are measured relative to the basal bone of the jaws while
skeletal changes are measured relative to the anterior cranial • Audio-visual reflex.
base. • Skeletal pattern
• Growth pattern
• Respiratory pattern
Uses of cephalometry
• Diagnosis and treatment planning before com-
mencing treatment
• During active orthodontic treatment
• End or near end of treatment
• Research purposes
References JACOBSON, A. 1975. The “Wits” appraisal of jaw disharmony. Am
J Orthod, 67, 125-38.
ABDULLAH, R. T., KUIJPERS, M. A., BERGE, S. J. & KATSAROS,
C. 2006. Steiner cephalometric analysis: predicted and actual treat- JACOBSON, A. 1976. Application of the “Wits” appraisal. Am J
ment outcome compared. Orthod Craniofac Res, 9, 77-83. Orthod, 70, 179-89.
AMRHEIN, V., GREENLAND, S. & MCSHANE, B. 2019. Scientists JOHNSTON, L. E., JR. 1996. Balancing the books on orthodontic
rise up against statistical significance. Nature Publishing Group. treatment: an integrated analysis of change. Br J Orthod, 23, 93-
102.
BALLARD, C. F. 1951. Recent work in North America as it affects
orthodontic diagnosis and treatment. Dent Rec (London), 71, 85- KAMALUDDIN, J. M., COBOURNE, M. T., SHERRIFF, M. & BIS-
97. TER, D. 2012. Does the Eastman correction over- or under-adjust
ANB for positional changes of N? Eur J Orthod, 34, 719-23.
BANERJEE, A., PICKARD, H. M. & WATSON, T. F. 2011. Pick-
ard’s manual of operative dentistry, Oxford university press. KUMAR, S., VALIATHAN, A., GAUTAM, P., CHAKRAVARTHY,
K. & JAYASWAL, P. 2012. An evaluation of the Pi analysis in the
BASS, N. M. 2003. Measurement of the profile angle and the aes- assessment of anteroposterior jaw relationship. J Orthod, 39, 262-9.
thetic analysis of the facial profile. J Orthod, 30, 3-9.
MCNAMARA, J. A., JR. 1984. A method of cephalometric evalua-
BJORK, A. 1947. The face in profile: an anthropological x-ray tion. Am J Orthod, 86, 449-69.
investigation on Swedish children and conscripts.
MERRIFIELD, L. L. 1966. The profile line as an aid in critically
BJORK, A. 1955. Facial growth in man, studied with the aid of evaluating facial esthetics. Am J Orthod, 52, 804-22.
metallic implants. Acta Odontol Scand, 13, 9-34.
MILLS, J. 1982. Principles and practice of orthodontics. London:
BJÖRK, A. 1954. Cephalometric X-ray investigations in dentistry. Churchill Livingstone. Longman Group Ltd.
Internat DJ, 4, 718-744.
MILLS, J. R. 1970. The application and importance of cephalometry
BJORK, A. & PALLING, M. 1955. Adolescent age changes in sagit- in orthodontic treatment. Orthodontist, 2, 32-47.
tal jaw relation, alveolar prognathy, and incisal inclination. Acta
Odontol Scand, 12, 201-32. NIJKAMP, P. G., HABETS, L. L., AARTMAN, I. H. & ZENTNER,
A. 2008. The influence of cephalometrics on orthodontic treatment
BROADBENT, B. H. 1937. Bolton standards and technique in orth- planning. Eur J Orthod, 30, 630-5.
odontic practice. The Angle Orthodontist, 7, 209-233.
PANCHERZ, H. 1982. The mechanism of Class II correction in
BRUKS, A., ENBERG, K., NORDQVIST, I., HANSSON, A. S., Herbst appliance treatment. A cephalometric investigation. Am J
JANSSON, L. & SVENSON, B. 1999. Radiographic examinations Orthod, 82, 104-13.
as an aid to orthodontic diagnosis and treatment planning. Swed
Dent J, 23, 77-85. RICKETTS, R. M. 1960. A foundation for cephalometric commu-
nication. American journal of orthodontics, 46, 330-357.
DOWNS, W. B. 1948. Variations in facial relationships; their sig-
nificance in treatment and prognosis. Am J Orthod, 34, 812-40. RICKETTS, R. M. 1961. Cephalometric analysis and synthesis. The
Angle Orthodontist, 31, 141-156.
DOWNS, W. B. 1952. The role of cephalometrics in orthodontic
case analysis and diagnosis. American Journal of Orthodontics, 38, STEINER, C. C. 1953. Cephalometrics for you and me. American
162-182. journal of orthodontics, 39, 729-755.
DOWNS, W. B. 1956. Analysis of the dentofacial profile. The Angle TWEED, C. H. 1946. The Frankfort-mandibular plane angle in
Orthodontist, 26, 191-212. orthodontic diagnosis, classification, treatment planning, and prog-
nosis. Am J Orthod Oral Surg, 32, 175-230.
GONZALEZ-ULLOA, M. 1962. Quantitative principles in cosmet-
ic surgery of the face (profileplasty). Plast Reconstr Surg Transplant TWEED, C. H. 1954. The Frankfort-mandibular incisor angle
Bull, 29, 186-98. (FMIA) in orthodontic diagnosis, treatment planning and progno-
sis. The Angle Orthodontist, 24, 121-169.
GONZÁLEZ-ULLOA, M. & STEVENS, E. 1968. The role of chin
correction in profileplasty. Plast Reconstr Surg, 41, 477-86. VAN LEEUWEN, E. J., MALTHA, J. C., KUIJPERS‐JAGTMAN, A.
M. & VAN’T HOF, M. A. 2003. The effect of retention on orth-
GUYER, E. C., III, E. E. E., JR., J. A. M. & BEHRENTS, R. G. 1986. odontic relapse after the use of small continuous or discontinuous
Components of Class III Malocclusion in Juveniles and Adoles- forces. An experimental study in beagle dogs. European journal of
cents. The Angle Orthodontist, 56, 7-30. oral sciences, 111, 111-116.
HARVOLD, E. J. S. L. 1974. P, The Activator in Interceptive Ortho- WILLIAMS, P. 1986. Lower incisor position in treatment planning.
dontics, CV, Mosby Co. Br J Orthod, 13, 33-41.
HOUSTON, W. J. 1989. Incisor edge-centroid relationships and WYLIE, W. L. 1947. The assessment of anteroposterior dysplasia.
overbite depth. Eur J Orthod, 11, 139-43. The Angle Orthodontist, 17, 97-109.
HOUSTON, W. J. & EDLER, R. 1990. Long-term stability of the
lower labial segment relative to the A-Pog line. Eur J Orthod, 12,
302-10.
42 Space Analysis In Orthodontics
4
Space Analysis In
Orthodontics
Written by: Mohammed Almuzian, Haris Khan, Ayesha Tariq, Hajira Arham, Amna Sabeeh Noor
In this Chapter
1. Clinical application of space analysis.
2. Basic terminologies in space analysis
3. Permanent dentition space analysis
4. Advantages and disadvantages of RLSA
5. Mixed Dentition Space Analysis
6. Symmetry of the arch
7. Bolton analysis
8. Bolton ratios, malocclusion and gender
Sdeficient
pace analysis is the process of calculation of excess or
widths of each tooth measured using vernier caliper or
dividers.
space in both arches for correcting a malocclusion
(Proffit et al., 2012). 3. Discrepancy between the space available and required is
the quantified crowding or spacing in the arch. A posi-
Clinical application of space analysis tive sign is given for spacing and a negative sign is given
These include: for crowding.
• Diagnosis Permanent dentition space analysis
• Treatment planning Royal London space planning/ RLSA
• Planning of anchorage RLSA was developed by a team at Royal London Hospital

in London (Kirschen et al., 2000a, Kirschen et al., 2000b).
• Planning the mechanics RLSA is a package of comprehensive tool to measure the
• Analysis of space requirements space requirements objectively. RLSA consists of two main
domains, space requirement and space provision.
• Informed consent
Domain 1: Assessment of space requirement
Basic terminologies in space analysis
This domain consists of six elements:
These include:
• Crowding or spacing
Arch perimeter: Distance from the mesial contact of the
first permanent molar to the mesial contact of the contralat- • Curve of Spee leveling
eral permanent first molar (Ngan et al., 1999) • Arch expansion
Arch width intermolar: Distance between the mesiobuc- • Anteroposterior position of incisor
cal cusp tip of the first permanent molar to the mesiobuccal
cusp tip point of the contralateral first permanent molar • Tooth angulation
Arch width intercanine: Distance between the canine cusp • Tooth inclination
tip to the cusp tip of the contralateral canine The first four elements affect space requirements significant-
Arch Depth or Arch length:The distance from a line per- ly while others contribute minimally.
pendicular to the line connecting the mesial surfaces of the Spacing and Crowding analysis include all teeth up to mesial
permanent first molars to the midpoint of central incisors. surface of 1st molars. The recommended method involves
Sometimes widest point of molars is used instead of mesial using a transparent ruler over the occlusal of maligned teeth
surface. parallel to the floor and as close as possible to the arch form
Arch expansion: Widening of the dental arch. that represent the majority of the teeth to measure the space
available. The total mesiodistal width of each individual
Arch lengthening: Increase of arch length by posterior tooth is measured, the sum of the individual tooth size is
teeth distalization or anterior proclination. subtracted from the arch perimeter to calculate the space
Study model analysis to assess space requirements surplus or deficiency. Crowding of two adjacent teeth can
also be assessed by measuring the mesiodistal widths of two
Study model analysis is either undertaken manually or with teeth and comparing it to the combined space available over
the aid of a computer (Schirmer and Wiltshire, 1997) and it the arch, however, this should not be performed on three
includes three measurements: or more teeth as the discrepancy between chord and arc
1. Arch perimeter / space available assessment increases. Chord is the distance measured in a straight line
and arc being the curvature of archform. Incisor that repre-
• Segmental technique: The arch is divided into four sent the archform should also be included in cephalometric
segments: two anterior segment; right and left (1-3), analysis and overjet measurement to avoid double counting.
and two posterior segment (3-6). A linear measure-
ment is made from 2 points of each segment. Leveling of the curve of Spee (COS): COS represents the line
passing through the buccal cusps and the incisal edges from
• Stainless steel (SS) / brass wire technique: A piece distal of lower 1st molar to the most anterior tooth of each
of dead-soft SS wire or a brass wire can be contoured quadrant. 2nd molars are not part of the COS as they are
to the arch and measured. often not fully erupted and may be aligned by tipping them
2. Space required assessment distally, therefore, not requiring any space creation. The
distance from the deepest point of the COS to the lower oc-
The space required represents the sum of the mesiodistal

clusal plane denote the depth of the COS (DoCOS). Space is movement (increase in the arch depth through procli-
required for leveling the COS though the amount of which nation) will provide 2mm of relief of crowding. A more
varies depending on the DoCOS. realistic parabolic archform is considered average, and
more than 1mm of labial movement will be required to
Mathematically, to calculate the space required (SR) to
create a space of 2mm.
flattened the COS, the following equation is considered
(SR=(DoCOS/2)-0.5), hence, to flatten DoCOS of 3mm, Proclining incisors by arch lengthening include three
4mm and 5mm, it is essential to provide 1mm, 1.5mm categories: changes in incisors anteroposterior position,
and 2mm of space respectively. torque and inclination. This is because of the wagon
wheel effect, therefore, it is summative and not a linear
The amount of the space required to flatten the COS be-
effect. A study in 1996 demonstrates the aforementioned
come constant if the DoCOS is more than 5mm i.e. very
fact, and also the effect of arch depth and width on the
deep COS (more than 6mm) requires only 2mm of space.
amount of space created by proclination of the incisors
Two considerations are important. First, space for occlu- (Steyn et al., 1996). The greater the intercanine widths
sal plane leveling should only be considered if the pre- and the shallower canine arch depths (from canine to
molars have not been marked as crowded, otherwise, it mid-incisor point) mean greater incisors proclination is
will lead to double counting as needing space for both required to relieve a given amount of crowding.
relief of crowding and for leveling. Secondly, not all oc-
Change in angulation (second order bend)
clusal planes need to be leveled, so, clinical judgment is
important. Teeth that are vertically upright take less space than teeth
that are at the correct angulation, with excessively angu-
Change in Arch width or Arch expansion/contraction
lated teeth take up more space. Approximately, 0.5mm of
Ideally, the distance between mesiobuccal cusp tips of space per tooth is required to change the angulation of
upper first permanent molars should be at least 2mm the teeth from upright to mesio-angular. This principle
wider than the lower first permanent molars (Gill and mainly applied in maxillary incisors, canines and man-
Naini, 2012). There is controversy in literature about the dibular canines. In most cases increased angulation is not
amount of space provided by expansion of the maxillary required.
arch. It has been suggested that for every 1mm for overall
Change in Inclination (torque or third order bend)
expansion of arch, 1mm of space is created, the reverse is
true for arch contraction. However, Lee and team con- Achieving a correct torque or inclination is essential for
cluded that for every 1mm of posterior arch width ex- stability, improved esthetics, ideal tooth contacts with
pansion, there is 0.56mm of space creation (Lee, 1999). minimal spacing, and good buccal occlusion. 0.25mm of
space is needed for each 5 degrees of palatal root torque,
The latest literature reported that for every 1mm of in-
if incisors are of average-shaped. If only two teeth are
creases in intermolar width, there is a reduction of
torqued palatally, then, a space of 0.5mm is required.
0.28mm of arch depth, which is equivalent to 0.56mm
This principle is usually used for maxillary incisors only.
decrease in arch perimeter. Hence, approximately 0.5
mm of space is remained for each 1 mm of expansion Lower incisors are not considered in this math unless se-
(O’Higgins and Lee, 2000). Other suggested that a net of verely proclined, as their contact points are close to the
0.7 mm of space is provided in premolar area for each 1 incisal edge. Incisor proclination is considered a summa-
mm of expansion (Adkins et al., 1990). Moreover, it is tive effect of anteroposterior and inclination changes.
important to notice that the space created from an in-
Molar Relationship
dividual tooth expansion is negligible in space analysis.
Three factors affect molar relationship:
Anteroposterior changes to Incisors
• Distalizing buccal segments, e.g., with Headgear or
There are few principles that need to be understood befor
any other distalization appliance.
e applying this domain of space analysis. Generally, it is
acceptable that the aims of treatment determine the po- • Mesial movement of buccal segments secondary to
sition of lower incisor whilst the upper incisor position anchorage loss.
is usually determined by achieving an overjet of 2mm.
• Differential jaw growth.
Overjet is measured with the mandible in retruded con-
tact position, both clinically and from lateral cephalo- When anteroposterior position of incisors has been taken
metric radiographs. 2mm of space is required for every into account, molar relationship is expressed as the differ-
1mm of change in the overjet. It has been proposed that ence in required space for upper and lower arches (Gill and
based on the archform being rectangular, 1mm of labial Naini, 2012). If the molar relation is Class I with the absence
of a tooth size discrepancy, the upper and lower arches
Space Analysis In Orthodontics 45

would have a similar space requirement. Other Methods for Space Analysis in Permanent Dentition
Domain 2: Utilisation or creation of space These include:
Generally, space can be created by different way, remember • Eye balling: It is a subjective inaccurate method to as-
SPEED TRIAL: sess crowding.
• Stripping of teeth (interproximal reduction or slander- • Visual Method: as mentioned in RLSA which is associ-
ization) ated with some disadvantages such as being not repro-
ducible, overestimates crowding (Johal and Battagel,
• Proclination of teeth
1997) and it is affected by the difference in lengths when
• Extraction considering the arch as an arc (curve) however taking
measurements as a cord (straight line). Moreover, the
• Expansion
use of ruler introduces accumulative error.
• Distalisation of molar
• Segmental Approach: Divide arch into four segments
• Torque changing that can be measured as a straight line, e.g., 6-3, 3-1,
• Rotation and de-rotation 1-3, 3-6, to calculate space available. The arch can also
be divided into six segments with the canine as inde-
• Incremental/ differential growth (positive for advanc- pendent segment to minimise the chord and arc differ-
ing Class II, and negative for advancing class III with a ential effect. The required space can be calculated as the
deterioration in arch relationship expected) total mesiodistal width of each individual tooth up to
• Angulation changing the first molar on each side (Moorrees and Reed, 1954).
Problem of this method is underestimating the available
• Leeway space and hence tends to drive treatment plan towards extrac-
The created space can be utilised by: tions (Johal and Battagel, 1997).
• Tooth enlargement or build-ups • Brass wire/ Caliper Method: To measure the space
available with this technique, adapt a brass wire to the
• Space opening for prostheses line of occlusion, conforming close to the archform and
• Mesial change in molar straighten it out in a line. To calculate space required,
measure the individual mesiodistal width of each tooth
Advantages and disadvantages of RLSA and add them together (Nance, 1947). The weaknesses
RLSA is a systematic method of analysis and treatment plan- of this technique is over-estimation of the available
ning, considering the main factors with require or generate space (Johal and Battagel, 1997).
space. Although the RLSA has been shown to be reliable and • Microscopic reflex technique: This technique uses a
valid its use has the following disadvantages: reflex microscope connected to a personal computer
• Does not account for vertical and transverse problems installed with a customized program. To calculate space
available, the software simply subtracts from the total
• Does not significantly affect decision for treatment tooth widths the mesiodistal overlaps of adjacent teeth,
planning including permanent first molars, making calculations
• Tends to overestimate crowding in millimeters. This technique have been previously
shown to be precise (Johal et al., 1995, Battagel, 1996),
• Tends to drive treatment plan towards extractions
however, the possible problems are expensive to use,
Is Royal London Space Analysis Reliable and does it influ- requires use of a specific computer program and the
ence orthodontic treatment decisions? maximum mesio-distal width is difficult to record if the
teeth are severely tipped.
Dr Al-Abdallah in her study found that (Al-Abdallah et al.,
2008): Methods of size estimation for unerupted teeth (Mixed
Dentition Space Analysis)
• RLSA is reliable.
Space analysis in mixed dentition requires estimation of
• RLSA did not influence treatment decision.
the size of unerupted teeth. This can be done in one of four
• RLSA may have an influence on visual perception. ways:
• RLSA does not have an impact on judgmental variation. 1. Study model and prediction table method
Moyer found a correlation between lower incisors and un-
erupted canine and premolars in a sample of North Ameri-

can Caucasian children (Moyers, 1973). It uses mesio-distal Symmetry of the Arch
widths of lower incisors to estimate canine size from propor-
An asymmetric arch can still be present even if the face is
tionality tables. Lower incisors were considered in prefer-
symmetric. This can be visualized on physical or virtual
ence to upper incisors due to large variability in the size of
casts by applying a transparent ruled grid over the upper
maxillary lateral incisors. This technique has a tendency to
cast and coinciding it with midpalatal raphe.
overestimate the size of the unerupted teeth.
Any distortions would be readily obvious. Some clinicians
2. Study model based method
prefer to orient the diagonal line connecting mesiolingual
Tanaka and Johnston 1974 assess the size of unerupted teeth and distobuccal cusp of maxillary 1st molar to the cusp tips
based on study model measurements only. Once memo- of upper canine bilaterally to confirm symmetry of arch.
rized, this technique requires no radiographs or tables. The
Tooth Size Analysis or Bolton analysis
steps include:
Teeth must be of proportional size for good occlusion
• Measuring the mesiodistal widths of lower incisors
(PROFFIT et al., 2012), similar to the principle of the box
(MD) in mm and divide it in half (MD/2),
(mandible) and lid (maxilla). For example, in a denture set-
• To calculate the total width of mandibular canine up, if large upper teeth are made to interdigitate with small
and premolars in one quadrant, add 10.5 mm to the lower teeth, ideal occlusion will not be possible and one of
above value (MD/2+10.5) two scenarios would represent the final outcome: either ideal
molar relationship with increased overjet or normal overjet
• To calculate the total width of maxillary canine and
with mesial occlusion of lower molars. This is called teeth
premolars in one quadrant, add 11 mm to the above
size discrepancy (TSD).
value (MD/2+11)
Maxillary lateral incisors and premolars show most predis-
3. Combination of Radiographs and Prediction Table
position to variation in size.
method (Staley and Kerber, 1980)
Bolton analysis
According to Staley and Kerber in 1980, the size of ca-
nines is difficult to predict from radiographs. Therefore, With reference from a standard table, it compares combined
this method uses mesiodistal measurements of incisors maxillary teeth’ mesiodistal widths to mandibular teeth, and
from models, and widths of premolars from radiographs compares total widths of all maxillary and mandibular teeth,
to estimate size of unerupted canines. except for 2nd and 3rd molars (Bolton, 1958).
A graph showing linear correlation was used to estimate Derived formula
the size of mandibular canine. Although the graph was
Overall ratio= sum of mandibular 12 x100
accurate, it only predicted the size of lower canine and
required radiographs. sum of maxillary 12
4. Magnification power technique Overall Bolton index (OBI) = 91.3% ± 1.91
This technique is easy to be performed as it requires an Anterior ratio= sum of mandibular 6 x100
undistorted periapical radiograph and study models. sum of maxillary 6
Radiographic enlargement must be taken into consider-
Anterior Bolton index (ABI) = 77.2% ± 1.65
ation.
These ratios can be a diagnostic tool for improved aesthetics
TwUP represents the true width of unerupted premolar,
and function, without using a diagnostic setup. For normal
TwSM represents the true width of an erupted decidu-
buccal segment size, the upper to lower buccal segment ratio
ous 1st molar on study model, RwEM represents the ra-
must be 1/1. Proffit suggested that a quick visual analysis of
diographic width of an erupted deciduous 1st molar and
anterior tooth size discrepancy can be checked by compar-
RwUP represents the radiographic width of unerupted
ing the size of upper laterals with lower lateral incisors and
premolar. To assess the TwUP the following calculation
concluded that the upper laterals must be of larger size. A
is applied: (TwSM /RwEM) X RwUP.
quick posterior tooth size discrepancy can be analysed from
This approach can be applied to all ethnic groups and a comparison of upper and lower 2nd premolars which must
used for both maxillary and mandibular teeth. Accuracy be of equal size (Proffit, 2000).
depends on the quality of radiographic image which is
When the ratio is greater than average mean it is either
poor for canines. Magnification errors make the use of
maxillary deficiency or mandibular excess, or a combination
photocopies of casts in computer programs unreliable
of both.
(Champagne, 1992)
The disadvantage of Bolton analysis is that it applies only to

white females who made up most of his sample. TSD can be TSD (Crosby and Alexander, 1989).
corrected through build-ups of upper laterals, tipping small Bolton ratios and extractions
upper laterals to take up more space, perform IPR in lower
arch or accept compromised molar relationship with de- Extraction of first premolars has a significant impact on TSD
creased overjet. Since it is time-consuming to use reference whereas 2nd premolar extraction has little effect (Saatçi and
tables, computer-aided programs for digitizing or scanning Yukay, 1997).
study casts are available, with the advantage that they are Bolton ratios and Diagnostic Set-up (DS)
quicker (Ho and Freer, 1999, Tomassetti et al., 2001).
• DS is used for planning of tooth movements and to
A study by Othman and Harradine (Othman and Harradine,
2007) showed that: exhibit effects of extraction e.g. when teeth are missing,
• Repeated measurements for tooth size discrep- in severe TSD or when a single lower incisor extraction
ancy are recommended as there is high degree of is planned.
non-reproducibility,
• Teeth are removed from planned extraction site on
• Computerized methods of assessment are
superior in sensitivity to visual methods, study models and relocated to final tooth positions to
• 17.4% of the sample had anterior tooth width demonstrate final positions. The teeth are held in their
ratios and 5.4% had total arch ratios greater than 2 new positions with wax.
standard deviations from the average mean.
Expressing tooth size discrepancy in mm is prefer- • DS can be performed digitally.
able to standard deviation approach. Therefore, a • DS is beneficial in that it aids patient understing
requirement of tooth size correction of 2mm is an
appropriate threshold for clinical significance.
Exam Night Review
Average widths of permanent teeth (mm)
Clinical application of space analysis
Maxillary 8.5 6.5 7.5 7.0 7.0 10.5 9.5 8.5
• Diagnosis,
1 2 3 4 5 6 7 8
Man- 5.0 5.5 7.0 7.0 7.0 10.5 9.5 8.5 • Treatment planning,
dibular • Planning of anchorage,
Bolton ratios, malocclusion and gender • Planning the mechanics,
Different authors have compared Bolton ratios in differ- • Analysis of space requirements,
ent malocclusions; maxillary tooth size excess tendency
• Informed consent.
was present in Class II malocclusions and a tendency for
mandibular tooth excess in Class III (Nie and Lin, 1999). Arch perimeter: Mesial contact of the 6 to the mesial con-
Another study also found a significant mandibular excess in tact of the contralateral 6
Class III patients and an overall decreased Bolton ratio in
Arch width intermolar: Mesiobuccal cusp tip of the 6 to
Class II cases (Araujo and Souki, 2003). From these find-
the mesiobuccal cusp tip point of the contralateral 6
ings, it can be speculated whether these discrepancies have
a role in establishing the associated incisor relationship with Arch width intercanine: Canine cusp tip to canine cusp tip
a malocclusion or if the skeletal discrepancy in a jaw and
Arch Depth: The distance from a line perpendicular to the
its compensatory increase in tooth size results from growth
mesial surface of the permanent first molars to the midpoint
controlled mechanisms
of central incisors at its greatest depth.
Bolton ratios and ethnic groups
Arch expansion: Widening of the dental arch.
Many studies have investigated a relationship between
Arch lengthening: Increase of arch length by posterior
ethnic groups and Bolton ratios. A study demonstrated a
distalization or anterior proclination of incisors.
small but significant difference between Hispanic, black and
white groups (Smith et al., 2000). A significant difference Permanent Dentition Space Analysis
was found between gender groups, suggesting that the entire RLSA consists of two main domains: space requirement and
Bolton sample was made up of white females. On the other space provision.
hand, some study showed that different malocclusions or
either genders do not present any significant difference in Assessment of Space Requirement

• Crowding or spacing, half (MD/2). To calculate the total width of mandible
3,4,5 add 10.5 mm to the above value (MD/2+10.5). To
• Curve of Spee leveling
calculate the total width of maxillary 3,4,5, add 11 mm
• Arch expansion to the above value (MD/2+11)
• Anteroposterior position of incisor • Combination of Radiographs and Prediction Table
method (Staley and Kerber, 1980): According to Staley
• Tooth angulation
and Kerber in 1980, the size of canines is difficult to
• Tooth inclination. predict from radiographs. Therefore, this method uses
Utilisation or creation of space mesiodistal measurements of incisors from models, and
widths of premolars from radiographs to estimate size
Generally, space can be created by different way, remember of unerupted canines.
SPEED TRIAL:
• Magnification power technique
• Stripping of teeth (interproximal reduction or slander-
ization) Bolton analysis
• Proclination of teeth Overall ratio= sum of mandibular 12 x100
• Extraction sum of maxillary 12
• Expansion Overall Bolton index (OBI) = 91.3% ± 1.91
• Distalisation of molar Anterior ratio= sum of mandibular 6 x100
• Torque changing sum of maxillary 6
• Rotation and de-rotation Anterior Bolton index (ABI) = 77.2% ± 1.65
• Incremental/ differential growth (positive for advanc- (Othman and Harradine, 2007) showed that:
ing Class II, and negative for advancing class III with a • Repeated measurements recommended
deterioration in arch relationship expected)
• Computerized methods of assessment are superior in
• Angulation changing sensitivity to visual methods
• Leeway space • 17.4% of the sample had anterior tooth width ratios and
Space can be utilised via: 5.4% had total arch ratios greater than 2 standard devia-
tions from the average mean
• Tooth enlargement or build-ups
• Expressing tooth size discrepancy in mm is preferable.
• Space opening for prostheses Requirement of tooth size correction of 2mm threshold
• Mesial change in molar for clinical significance
Other Methods for Space Analysis in Permanent Denti-

tion
• Eye balling
• Visual Method
• Segmental Approach
• Brass wire/ Caliper Method
• Microscopic Reflex Technique
Methods of size estimation for unerupted teeth (Mixed
Dentition Space Analysis)
• Study model and prediction table method: It uses
mesio-distal widths of lower incisors to estimate canine
size from proportionality tables.
• Study model based method: Measuring the mesiodistal
widths of lower incisors (MD) in mm and divide it in

References 223.
ADKINS, M. D., NANDA, R. S. & CURRIER, G. F. 1990. Arch NGAN, P., ALKIRE, R. G. & FIELDS JR, H. 1999. Management of
perimeter changes on rapid palatal expansion. Am J Orthod Den- space problems in the primary and mixed dentitions. The Journal
tofacial Orthop, 97, 194-9. of the American Dental Association, 130, 1330-1339.
AL-ABDALLAH, M., SANDLER, J. & O’BRIEN, K. 2008. Is the NIE, Q. & LIN, J. 1999. Comparison of intermaxillary tooth size
Royal London Space Analysis reliable and does it influence orth- discrepancies among different malocclusion groups. American
odontic treatment decisions? Eur J Orthod, 30, 503-7. Journal of Orthodontics and Dentofacial Orthopedics, 116, 539-
544.
ARAUJO, E. & SOUKI, M. 2003. Bolton anterior tooth size
discrepancies among different malocclusion groups. The Angle O’HIGGINS, E. A. & LEE, R. T. 2000. How much space is created
orthodontist, 73, 307-313. from expansion or premolar extraction? J Orthod, 27, 11-3.
BATTAGEL, J. M. 1996. Individualized catenary curves: their rela- OTHMAN, S. A. & HARRADINE, N. W. 2007. Tooth-size dis-
tionship to arch form and perimeter. Br J Orthod, 23, 21-8. crepancy and Bolton’s ratios: the reproducibility and speed of two
methods of measurement. J Orthod, 34, 234-42; discussion 233.
BOLTON, W. A. 1958. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. The Angle Orthodon- PROFFIT, W. R. 2000. Masters of esthetic dentistry: The soft tissue
tist, 28, 113-130. paradigm in orthodontic diagnosis and treatment planning: A
new view for a new century. Journal of Esthetic and Restorative
CHAMPAGNE, M. 1992. Reliability of measurements from photo- Dentistry, 12, 46-49.
copies of study models. J Clin Orthod, 26, 648-50.
PROFFIT, W. R. F., FIELDS JR, H. W. & SARVER, D. M. 2012.
CROSBY, D. R. & ALEXANDER, C. G. 1989. The occurrence of Contemporary Orthodontics, 5e, Elsevier India.
tooth size discrepancies among different malocclusion groups. Am
J Orthod Dentofacial Orthop, 95, 457-61. SAATÇI, P. & YUKAY, F. 1997. The effect of premolar extractions
on tooth-size discrepancy. American journal of orthodontics and
GILL, D. S. & NAINI, F. B. 2012. Orthodontics: Principles and dentofacial orthopedics, 111, 428-434.
practice, John Wiley & Sons.
SCHIRMER, U. R. & WILTSHIRE, W. A. 1997. Manual and
HO, C. T. & FREER, T. J. 1999. A computerized tooth-width analy- computer-aided space analysis: a comparative study. Am J Orthod
sis. J Clin Orthod, 33, 498-503. Dentofacial Orthop, 112, 676-80.
JAROONTHAM, J. & GODFREY, K. 2000. Mixed dentition space SMITH, S. S., BUSCHANG, P. H. & WATANABE, E. 2000. Inter-
analysis in a Thai population. Eur J Orthod, 22, 127-34. arch tooth size relationships of 3 populations: “does Bolton’s analy-
JOHAL, A. S. & BATTAGEL, J. M. 1997. Dental crowding: a com- sis apply?”. Am J Orthod Dentofacial Orthop, 117, 169-74.
parison of three methods of assessment. Eur J Orthod, 19, 543-51. STALEY, R. N. & KERBER, P. E. 1980. A revision of the Hixon and
JOHAL, K., CRAIG, G., DEVLIN, A., BROOK, I. & HILL, R. 1995. Oldfather mixed-dentition prediction method. Am J Orthod, 78,
In vivo response of ionomeric cements: effect of glass composition, 296-302.
increasing soda or calcium fluoride content. Journal of Materials

STEYN, C. L., HARRIS, A. M. & DU PREEZ, R. J. 1996. Anterior
Science: Materials in Medicine, 6, 690-694. arch circumference adjustment--how much? Angle Orthod, 66,
KIRSCHEN, R. H., O’HIGGINS E, A. & LEE, R. T. 2000a. The 457-62.
Royal London Space Planning: an integration of space analysis TOMASSETTI, J. J., TALOUMIS, L. J., DENNY, J. M. & FISCHER,
and treatment planning: Part I: Assessing the space required to J. R., JR. 2001. A comparison of 3 computerized Bolton tooth-size
meet treatment objectives. Am J Orthod Dentofacial Orthop, 118, analyses with a commonly used method. Angle Orthod, 71, 351-7.
448-55.
KIRSCHEN, R. H., O’HIGGINS, E. A. & LEE, R. T. 2000b. The
Royal London Space Planning: an integration of space analysis and
treatment planning: Part II: The effect of other treatment proce-
dures on space. Am J Orthod Dentofacial Orthop, 118, 456-61.
LEE, R. T. 1999. Arch width and form: a review. Am J Orthod
MOORREES, C. F. & REED, R. B. 1954. Biometrics of crowding
and spacing of the teeth in the mandible. Am J Phys Anthropol, 12,
77-88.
MOYERS, R. 1973. Maturation of orofacial musculature, Hand-
book of Orthodontics, 3rd Edit. Year Book Medical Publishers Co.,
Chicago, 135-137.
NANCE, H. N. 1947. The limitations of orthodontic treatment;
mixed dentition diagnosis and treatment. Am J Orthod, 33, 177-

5
Orthodontic Indices
Written by: Mohammed Almuzian, Haris Khan, Ayesha Tariq, Hajira Arham
In this Chapter
1. Uses of orthodontic indices 13. Crowding index

2. Ideal characteristics of an index 14. Maxillary expansion indices
3. Types of indices 15. Treatment difficulty index for unerupted maxil-
4. Angle’s classification lary canines
5. Incisor classification 16. Plaque index
6. Index of Orthodontic Treatment Need (IOTN) 17. Gingival index (GI)
7. An Index of Orthognathic Functional Treatment 18. Basic Periodontal Examination (BPE)
Need (IOFTN) 19. Helkimo Clinical Dysfunction (HCD) Index
8. Peer Assessment Rating (PAR) 20. GOSLON index
9. Index Of Complexity Outcome & Need (ICON) 21. Tooth Wear Index
10. American Board of Orthodontics Discrepancy 22. Root resorption indices
Index (ABO DI) 23. Maxillary suture fusion index
11. Handicapping Malocclusion Assessment Record 24. EXAM NIGHT REVIEW
12. Little irregularity (LI) index
A n orthodontic index can be defined as a means of objec-
1. Indices used for classification of the malocclusion such
tively assessing occlusal status directly or indirectly. Indices
aim to determine one or more of the below features: as:
• Complexity: Defined as intricate or complicated. • Skeletal classification
• Difficulty: Defined as need of effort and skill. • Soft tissue classification
• Severity: Defined as how far a malocclusion deviates • Occlusal classification such as Angle’s, incisor and
from normal. canine classifications.
Uses of orthodontic indices 1. Indices used for diagnostic purposes such as:
Indices in orthodontics have many applications, these in- • Occlusal index

clude: • Handicapping Malocclusion Assessment Record
1. Epidemiology applications such as: 2. Indices used for assessment of treatment needs, com-
• Determining the prevalence and incidence of oc- plexity and outcome such as:
clusal anomalies. • Index of orthodontic treatment needs (IOTN)
• Economic health care resource planning (financial • Little’s irregularity index
and workforce planning).
• Peer Assessment Rating (PAR)
• For academic research.
• ICON
2. Clinical assessment such as:
3. Indices used for assessment of cleft lip/ palate treat-
• Classification of malocclusion (e.g. Angle’s classifi- ment outcomes such as:
cation, incisor classification).
• GOSLON Yardstick
• Diagnostic indices (e.g. Occlusal index).
• 5-year Old’s Index
• Treatment need or prioritisation (e.g. IOTN).
• Bergalnd index for secondary alveolar bone graft-
• Treatment complexity and difficulty assessment (e.g. ing (SABG)
ICON).
• Kindealan index for SABG
• Treatment outcome and success assessment (e.g.
4. Oral health indices such as:
PAR).
• Plaque Index
3. Communication purposes with patients regarding their
malocclusion and for professional communication with col- • Community periodontal index for treatment needs
leagues. (CPITN)
Ideal characteristics of an index • Gingival Index
These include: Angle’s classification
• Reliable Angle’s classification assesses the anterior-posterior relation-
ship regarding the first permanent molars. Angle described
• Reproducible
three classes in 1899:
• Valid
• Class 1 (neutrocclusion): The mesiobuccal cusp of
• Cost-effective the upper first permanent molar occludes with the buc-
• Universally acceptable cal groove of the lower first permanent molar.
• Requires minimal adjustment • Class 2 (distocclusion / post-normal): When the

mesiobuccal cusp of the upper first permanent molar
• Simple to administer occludes mesial to the buccal groove of the lower first
Types of indices permanent molar.
There are different types of orthodontic indices depending • Class 3 (mesiocclusion/ Pre-normal): when the
on their applications and purposes, these include: mesiobuccal cusp of the upper first permanent molar
occludes distal to the buccal groove of the lower first
52 Orthodontic Indices
permanent molar • Modification to the incisor classification includes
Class 2 indefinite which means that one upper cen-
Modification to Angle’s classification
tral incisor is retroclined, and the other is proclined
Includes Class 2 subdivision (Class 2 molar on one side
(Gravely and Johnson, 1974) and Class 2 intermediate
and class 1 molar on the other side) and Class 3 subdivision
which refers to a clinical situation where the upper inci-
(Class 3 molar on one side and class 1 molar on the other
sors are upright or slightly retroclined, and the overjet is
side). Angle’s classification is a simple, widely accepted,
5-7 mm (Williams and Stephens, 1992).
reliable and reproducible method of occlusal classification.
However, it cannot be used in primary dentition, the dental Skeletal classification
or skeletal original of aetiology cannot be distinguished, it
Skeletal classification is obtained through clinical assessment
can only assess discrepancies in the sagittal direction. More-
and supported with cephalometric analysis. Three skeletal
over, this method depends on the first permanent molars
categories are described using ANB angle:
being fixed points in the jaw structure, which is not valid, as
environmental factors can affect their position. • Class 1: Lower dental base is related to the upper
dental base (ANB= 2-4˚).
Full unit Class 2 and Class 3 malocclusion
• Class 2: Lower dental base is retruded relative to the
One unit is defined as the mesial-distal width of a premolar
upper dental base (ANB> 4˚).
and represents the distance from the mesiobuccal cusp tip
to the distobuccal cusp tip of the first permanent molar. Full • Class 3: Lower dental base is protruded relative to
unit Class 2 means that the mesiobuccal cusp of the upper the upper dental base (ANB <2˚).
molar is one unit mesial to the buccal groove of the lower
Wits appraisal and Ballard conversion can be used similarly
molar, i.e., the upper molar’s mesiobuccal cusp occludes in
to ANB.
the embrasure space of the lower second premolar and lower
first permanent molar. While, full unit class 3 means that Index of Orthodontic Treatment Need (IOTN)
the mesiobuccal cusp of the upper molar is one unit distal to IOTN was developed by Brook (Brook and Shaw, 1989),
the buccal groove of the lower molar, i.e., the upper molar’s who developed a specific ruler to aid assessment. IOTN
mesiobuccal cusp occludes in the embrasure space of the has two components: Dental health component (DHC) and
lower first permanent molar and second molar. Fractions of Aesthetic component (AC).
the unit are also used, commonly ¼, ½ , ¾ unit Class 2 and
Class 3
Incisor classification With regards to the Dental Health Component (DHC),
Brook and Shaw showed the reproducibility of the DHC is
The incisor classification was developed by the British very good (86.4%), and agreement was moderate for intra
Standards Institutes in 1983. It is based on the lower incisor and inter-examiner agreement (0.84-0.71). They also found
edges and the upper central incisor cingulum plateau. These that the common trait causing disagreement in descending
include: order of frequency are: crowding, increased overjet, cross-
• Class 1: The lower incisor edges occlude with or lie bites and overbites (Brook and Shaw, 1989).
immediately below the cingulum plateau of the upper With regards to the Aesthetic Component (AC), a high
incisors. level of agreement was found between patients, parents and
• Class 2: The lower incisor edges occlude or lie orthodontists when grading the patient’s AC (0.75-0.89)
posterior to the cingulum plateau of the upper incisors. (Evans and Shaw, 1987). This was supported by a separate
Two divisions of this class were described: study which showed the correlation coefficient was reason-
ably high (Brook and Shaw, 1989).
1. Division 1: The upper incisors are pro-
clined or normal inclination, with an increased
overjet. Dental health component (DHC)
2. Division 2: The upper central incisors are This was developed based on the index treatment priority
retroclined (lateral incisors may be retroclined used by the Swedish Dental Board. It attempts to rank mal-
or proclined). The overjet is usually decreased occlusion, and it is used as a clinical tool to assess eligibility
but may be increased. for NHS treatment. The DHC consists of 14 qualifiers and
• Class 3: The lower incisor edges occlude or lie 5 grades (Figures 1 and 2). Only the highest-scoring trait
anterior to the cingulum plateau of the upper incisors. needs to be recorded, as this determines the patient’s grad-
Overjet is usually reduced or reversed. ing. Grades 1 and 2 represent no need for orthodontic treat-
ment, grade 3 refers to the borderline need for treatment
Orthodontic Indices 53
while grades 4 and 5 indicate the definite need for treatment. 4b, 4m,5m) (Figure 3). If the reverse overjet is greater than 1
mm, it is essential to investigate whether the individual has
masticatory or speech (M&S) difficulties and classify
a overjet h hypodontia
b reverse overjet with no masticatory or speech i posterior lingual crossbite
problems
c crossbite m reverse overjet with masticatory or speech problems
d deisplacemnet of contact points p defects of cleft lip and palate
e open bite s submerged deciduous teeth
f deep bite t partially erupted teeth, tipped and impacted against adjacent
teeth
g good occlusion x presence of supernumerary teeth
Table 1: Abbreviations used in IOTN
accordingly. There are several methods of investigation, but
Scoring the DHC a simple approach is to ask the individual to count from 60-
Scoring the DHC is performed in order as follows MOCDO 70, noting any difficulty in pronunciation. In addition, any
which stands for: M - Missing teeth, O – Overjet, C – Cross- signs and symptoms of mandibular dysfunction should be
bites, D - Displacements and O – Overbite. checked.
1. Missing teeth (5i, 5h or 4h) relates to impacted/ impeded Positive Overjet Reveres Overjet
eruption and hypodontia.
2. a compe- 3.5mm - 2. b 0mm - 1mm
• Impeded eruption (5i) is a score for a tooth that is tent lips 6mm
not accommodated in the arch due to a lack of space 3. a incom- 3.5mm - 3. b 1mm -
or obstruction. The tooth is considered impeded if petent lips 6mm 3.5mm
the space remaining is less than or equal to 4mm,
4. a 6mm - 4. m M&S prob- 1mm -
and the angulation is not favourable in the horizon-
9mm lems 3.5mm
tal direction. In the mixed dentition, if the distance
from the mesial contact point of the first permanent 4. b No M&S greater than
molar to the distal contact point of the lateral incisor problem 3.5mm
is less than 18 mm or 17 mm in the upper and lower 5. a greater 5.m M&S prob- greater than
dental arches, respectively, the unerupted canine is than lem 3.5mm
considered impacted. 9mm
• Hypodontia (5.h or 4.h): The IOTN classification Table 2: Positive and negative overjet in IOTN
of hypodontia is only used if the space requires
orthodontic treatment, i.e., space opening or space 3. Crossbite: When 1, 2 or 3 (but not all) incisors are in lin-
closure. If there is no requirement for orthodontic gual occlusion/crossbite, the relationship is classified as ante-
treatment, i.e., accept space or primary tooth in situ, rior crossbite (2.c, 3.c, 4.c, 4.l) (Table 3). Posterior crossbite
this does not meet the IOTN classification due to no means that the posterior tooth or teeth are in full crossbite
orthodontic treatment being required. 5h means in a buccal or lingual perspective or cusp to cusp and might
extensive hypodontia with more than one tooth be associated with a displacement. The grade recorded
missing in a quadrant, requiring pre-restorative or- depends on the severity of discrepancy between retruded
thodontics. 4h means less extensive hypodontia, one contact position (RCP) and intercuspal position (ICP). The
tooth missing in a quadrant, requiring orthodontic greater the discrepancy between RCP an ICP, the higher the
space closure or pre-restorative orthodontics. grade. Scissor bite means that the entire buccal segment in
lingual occlusion.
2. Overjet is measured using the ruler held parallel to the
occlusal plane and radial to the line of the arch (2a, 3a, 4a, Grade and Qualifier Discrepemcy between IP and RCP
5a) (Table 2). The overjet is recorded to the labial aspect of 2.c 1<=1mm
the incisal edge of the most prominent incisor (lateral or
central incisors). The lower grade is allocated if the incisor 3.c 1 - 2mm
falls on the IOTN ruler line. Reverse overjet applies when 4.c >2mm
all four incisors are in lingual occlusion/crossbite (2b, 3b,
Table 3: Crossbite in IOTN
Grade 5 Increased overjet > 9mm
(very great) Extensive hypodontia with restorative implicatoins (more than one tooth missing in any quadrant) requir-
ing pre-restorative orthodontics
Impeded eruption of teeth (with the exception of the third molars) due to corwding, displacements, the
presence of supernumeray teeth, retained deciduoud teeth and any pathological cause
Reverse overjet greater than 3.5mm with reported masticatory and speech difficulities
Defects of cleft lip and palate
Submerged deciduous teeth
Grade 4 Increased overjet > 6mm but 9mm
(great) Reverse overjet > 3.5mm with no masticatory or speech deifficulties
Anterior or posterior crossbite with > 2mm discrepency between returded contact position and intercuspal
position
Servere displacemetns of teeth > 4mm
Extreme lateral or anterior openbite > 4mm
Increased and complete overbite with labial or palatal trauma
Less Extensive hypodontia (one tooth missing per quadrant) requiring prerestorative othodontics or orth-
odontic space closure to obviate the need for a prosthesis
posterior lingual cross bite with no functional
occlusal contact in one or more buccal segments
Reverse overjet greater than 1mm but 3,5 mm with recorded masticatory and speech difficulties
Partially erupted teeth, tipped and imapcted against adjacent teeth
Supplemental teeth
Grade 3 Increased overjet > 3.5 mm but 6mm with incompetent lips
(moderate) Reverse overjet greater than 1mm but 3.5mm
Anterior or posterior cross bite with > 1mm but 2mm discrepency between returded contact position and
intercuspal position
Displacement of teeth > 2mm but 4mm
Lateral or anterior open bite greater than 2mm but 4mm
Grade 2 Increased overjet > 3.5 mm but 6mm with competent lips
(Little) Reverse overjet greater than 0mm but 1mm
Anterior or posterior cross bite with 1mm discrepency between returded contact position and intercuspal
position
Displacement of teeth > 1mm but 2mm
Anterior posterior openbite > 1mm but 2mm
Increased overbite 3.5mm without gingival contact
Prenormal or postnormal occlusions with no other anomalies. includes up to half a unit discrepency
Grade 1 EXtremely minor malocclusions including displacements < 1mm
(None)
Table 4: Dental health component (DHC) of IOTN
4. Displacement of contact points (2.d, 3.d, 4.d) (Table or poor colour matching in anterior restorations.
5) Contact point displacement represents the degree of
Within the UK NHS a patient with a DHC of 3 or more, and
anatomical contact points deviation from the line of the
an AC of 6 or more, qualify for state-funded NHS treatment.
arch and only the worst displaced tooth is recorded, how-
Treatment priority and need according to the AC scale are:
ever, vertical displacements from the occlusal plane are not
recorded. Spacing is not also recorded unless the contact • Grades 1-3: No/slight need for treatment.
point is displaced from the line of the arch. Contact points
• Grade 4: Mild need for treatment.
displacement between deciduous and permanent, and that
due to teeth rotation (generally premolars) are not recorded. • Grades 5-7: Borderline need for treatment.
• Grades 8-10: Definite need for orthodontic treat-
Grade and Qualifier Displacement
ment.
2. d 1mm - 2mm
3. d 2.1mm - 4mm Overbite Openbite
4. d greater than 4mm Grade Grade
and and
Table 5: Contact point displacement in IOTN Qualifier Qualifier
5. Overbite and openbite (2.e/f, 3.e/f, 4.e/f) (Table 6): Deep 2. f Increased 2.e Anterior or pos-
bite and open bite apply to any of the four incisors. The larg- greater than or terior openbite
est vertical discrepancy is recorded. It is important to record equal to 3.5mm 1mm - 2mm
gingival or palatal trauma as a result of a deep overbite. 3.f Deep overbite 3.e Anterior or pos-
Other criteria of the DHC complete on terior openbite
labial or palatal 2.1mm - 4mm
These include:
tissues but no
• Buccal occlusion (2g): The buccal occlusion is as trauma
• sessed irrespective of whether the teeth interdigitate 4.f Increased 4.e External lateral
in Angle’s Class 1, 2 or 3. and complete openbites great-
overbitewith er than 4mm
• Tipped teeth (4t): When a permanent tooth has labial or palatal
erupted and is tipped against an adjacent tooth. trauma
• Submerging teeth (5.s): Submerged teeth are not re- Table 6 : Overbite and openbite in IOTN
corded unless only two cusps remain visible and/or
the adjacent teeth are tipped towards the submerged
tooth. Index of Orthognathic Functional Treatment Need
• Supernumerary teeth (4.x): It is graded only if a su (IOFTN)
pernumerary tooth requires extraction followed by IOFTN was developed in 2014. It prioritizes severe maloc-
orthodontic alignment and/or space closure. clusions due to skeletal abnormalities, not amenable to
Aesthetic Component (AC) orthodontic treatment alone. It applies to patients who have
completed facial growth (Ireland et al., 2014) (Figure 9).
AC was developed by Evans (Evans and Shaw, 1987) and it
was originally called the SCAN (Standardised Continuum he advantages of IOFTN including being reliable and
of Aesthetic Need) (Figure 7 and 8). The photographs were straightforward to use (Howard-Bowles et al., 2017) and
originally arranged in order by a panel of lay persons. The both digital and plaster models can be used (McCrory et al.,
AC is a ranking system 1-10 using coloured photographs 2018). However, the limitation of IOFTN are that this index
which assess dental attractiveness. The number 1 is the most only relates to the functional need for treatment, it does not
attractive while number 10 is the least attractive (figure 7). include psychological and other clinical indicators for treat-
The grading is made by the clinician by best matching the ment. Moreover, Class 3 malocclusion patients benefit more
patient front occlusion to AC photographs but not specific from this index than patients with class 2 skeletal patterns
morphological similarities to the photo. (Borzabadi-Farahani et al., 2016).
Monochromic photographs are used for dental cast assess-

ments. (Woolass and Shaw, 1987). It has been reported that Advantages and disadvantages of the IOTN
monochromic photographs have the advantage that asses-
sors are not influenced by oral hygiene, gingival condition, Table 7 explain the advantages and disadvantages of the
IOTN. Peer Assessment Rating (PAR)
Advantages Disadvantages This index was developed by Richmond and team (Rich-
mond et al., 1992). It was formulated over a series of six
Valid Crowding represented a prob- meetings in 1987 with a group of 10 experienced orthodon-
lem in recording when the pa- tists. The index can record the malocclusion at any stage of
tient is in the mixed dentition. treatment where a score is assigned to various occlusal traits
Reproducible The AC has no side view rating of a malocclusion. The individual scores are summed to ob-
or class III malocclusion tain an overall total, representing the degree a case deviates
Acceptable to clinician Objective index from ideal alignment and occlusion.
Easy and quick to apply No representation of aesthetic Study models are used for scoring along with a specifically
or skeletal relationship designed ruler that has all the information summarized
Can be used directly on No assessment of crowding which makes measurement quick and easy to perform.
patients or on dental which relies on displacement A total score of zero indicates good alignment and higher
casts only scores (rarely beyond 50) indicate significant levels of ir-
Yield quantitative data regularity. The difference between the pretreatment and
which can be analysed posttreatment scores represent the degree of improvement as
a result of orthodontic intervention and active treatment.
Table 7: Advantages and disadvantages of the IOTN
A
There are 11 components of the PAR index:
1. Upper anterior segment.
2. Lower anterior segment.
3. Upper right segment.
4. Upper left segment.
5. Lower right segment.
6. Lower left segment.
7. Right buccal occlusion.
8. Left buccal occlusion.
Figure 7: Monochromic copy of AC scale. 9. Overjet.
10. Overbite.
11. Centreline
Anterior segments
Anterior segments with a weighting of 1, extends from the
mesial anatomical contact point of the canine to the mesial
anatomical contact point of the canine on the contralateral
side (Table 8). Displaced contact points are not recorded for
the first, second and third molars, this is because contact
points are broad and are extremely variable within the
normal range. Displaced contact points are recorded at the
shortest distance between contact points, parallel to the
occlusal plane. The occlusal features recorded are crowding,
spacing, and impacted teeth.
In the case of potential crowding in the mixed dentition,
Figure 8: Aesthetic component of the IOTN average mesiodistal widths are used to calculate the space
deficiency. Impacted teeth are recorded when the space
available for the tooth is equal or less than 4 mm (Table 9).
5. Very great need of treatment
Defects of cleft lip and palate and other craniofacial anomalies
Increased overjet greater than 9mm
Reverse overjet >= 3mm
Open bite >= 4mm
Complete scissors bite affecting whole buccal segments with sign of functional disturbance and or occlusal trauma
Sleep apnoea not amenable to other treatments such as MAD or CPAP (as determined by sleep studies)
Skeletal anomalies with occlusal disturance as a result of trauma or pathology
4. Great need of treatment
Increased overjet >= 6mm and <=9mm
Reverse overjet >= 0mm and < 3mm with functianl difficulties
Openbite < 4mm with functioanl difficulties
Increased overbite with evidence of dental or soft tissue trauma
Upper labial segment gingival exposure 3>= at rest
Facial asymmertry assocaited with occlusal disturbance
3. Moderate need of treatment
Reverse overjet >= 0mm and <3mm with no functionl difficulties
Open bite < 4mm with no functional difficulties
Upper labial segment gingival exposure <3mm at rest, but with evidence of gingival/periodontal effects
Facial asymmetry with no occlusal disturbance
2. Mild need of treatment
Increased overbite but no evidence of dental or soft tisssue trauma
Upper labial segement gingival exposure < 3mm at rest with no evidence of gingival/periodontal effects
Facial asymmetry with no occlusal disturbance
1. No need of treatment
Speech Difficulties
Treatment purely for TMD
Occlusal features not classified above
Table 9: An Index of Orthognathic Functional TreatmentNeed (IOFTN)
Displaced contact points due to poor restoration, contact

PAR Score Amount of teeth displace-
points between deciduous teeth and orthodontic extraction
ment
spaces are not recorded. Spacing in the anterior segment
resulting from extraction, agenesis or avulsion of incisors or 0 0 mm – 1mm
cuspids is recorded as follows: 1 1.1 mm – 2mm
• If the plan is to close space, then the space is record- 2 2.1 mm – 4mm
ed. 3 4.1 mm- 8mm
• If the plan is to open space and restore it, then the 4 Greater than 8mm
space is not recorded unless it is less than or equal 5 Impacted teeth
to 4 mm. Table 9: Anterior crowding
Table 10: Mixed dentition crowding assessment using Overjets and crossbites are recorded collectively, therefore, if
average mesio-distal width there is a positive overjet and one of the incisors or canines
in crossbite, the scores should be added together. Overjet
Upper has a weighting of 6.
Canine 8mm Total 22mm
Table 12: Overjet component measurements
1st Premolar 7mm Impaction < =
18mm Overjet Anterior crossbites
0 0-3 mm 0 No discrepancy
2nd Premolar 7mm
1 3.1- 5mm 1 One or more teeth
Lower edge to edge
Canine 7mm Total 21mm 2 5.1- 7mm 2 One single tooth in
1st Premolar 7mm Impaction < = crossbite
2nd Premolar 7mm 17mm 3 7.1- 9mm 3 Two teeth in cross-
bite
Buccal occlusion
4 Greater than 4 More than two
Buccal segments, with a weighting of 1, extends from the 9mm teeth in crossbite
mesial anatomical contact point of the last molar (whether
this was the first, second or third molar) to the distal ana-
tomical contact point of the canine in the same quadrant. Overbite
Recordings of both right and left sides in occlusion in three The vertical overlap (OB) or openbite (AOB) of the anterior
dimensions (A-P, vertical and transverse) is performed teeth is recorded (Table 13 & 14). The tooth with the greatest
(Table 10). Temporary developmental stages and submerg- overlap is recorded, if the OB and AOB are present, then they
ing deciduous teeth are excluded should be added. Overbite has a weighting of 2.
Table 11: Buccal occlusion assessment Table 13: Overbite component measurements
PAR Score Table 4: Buccal occlusion Open bite
discrepancy
0 No openbite
Vertical
1 Openbite less than and equal to
0 No discrepancy in intercuspa- 1mm
tion
2 Openbite 1.1 mm – 2 mm
1 Lateral open bite on at least 2
teeth greater than 2 mm 3 Openbite 2.1 mm- 3 mm
Antero-posterior 4 Openbite greater than or equal
4mm
0 Good interdigitation (Cl 1, Cl
2 or Cl 3) Table 14: Deep bite component measurements
1 Less than ½ unit discrepancy
0 Less than or equal to 1/3
2 ½ a unit discrepancy (cusp to
coverage of the lower incisor
cusp) or more
1 Greater than 1/3, but less
Transverse
than 2/3 coverage of the
0 No crossbites lower incisor
1 Crossbite tendency
2 Greater than 2/3 coverage of
2 Single tooth in crossbite the lower incisor
3 More than 1 tooth in crossbite 3 Greater than or equal to full
4 More than 1 tooth in scissor tooth coverage.
bite
Centerlines
Overjet
Centerline discrepancy is assessed in relation to the lower
The most prominent aspect of any incisor (central or lateral) central incisors (Table 15). If a lower incisor is missing, mea-
is recorded with a ruler held parallel to the occlusal plane surement is not recorded. Centerlines has a weighting of 4.
(Table 12).
Table 15: Centrelines component measurements provement or worse outcome.
PAR Score Table 8: Centrelines discrepancy as- • Graphical assessment: Assessment using a graph
sessment (nomogram).
0 Coincident and up to ¼ lower inci- Index Of Complexity Outcome & Need (ICON)
sor width
1 ¼ to ½ lower incisor width ICON index was purposed by Daniels (Daniels and Rich-
2 Greater than ½ lower incisor width mond, 2000) as the first index based on international orth-
odontic opinion of 97 orthodontists. ICON index comprises
Advantages of PAR index of an assessment of five traits, each trait is multiplied by a
These include: weighting factor. The final score is the sum of all the five trait
scores. ICON scoring and interpretations are provided in
• It has been reported that the PAR index has ex- Table 16 & 10.
cellent reliability within intra and inter-examiner
agreement (0.93-0.87) (Richmond et al., 1992). he traits which make up the ABO DI are presented in Table
10 and include:
• Easy and quick with use of the PAR ruler.
• Overjet and anterior crossbite.
• PAR can be used for all types of malocclusion and
treatment modalities. • Overbite and anterior open bite and lateral open-
bite.
• The score provides an estimate of how far a case de-
viates from normal. • Crowding.
• PAR is a good tool in measuring the perceived de- • Buccal occlusion.

gree of improvement and therefore the success of • Lingual posterior crossbite and buccal posterior
treatment and clinical performance. crossbite.
Disadvantages of PAR index • Cephalometric analysis: Consisting of ANB angle,
These include: SN-Go-Gn and lower incisor to Go-Gn angle.
• It provides a single summary score for all the oc- • An additional category designated ‘other’ is pre-
clusal anomalies, and is therefore not related to an served for conditions that may affect or add to the
individual patient’s needs. complexity of treatment.
• The reliability of the upper buccal segments was Need and acceptability Threshold values
found to be low, this was due to the variation of up- Pretreatment need >43 Treatment need
per posterior tooth size. Larger teeth have broader
contact points which result in inaccurate assessment
End treatment acceptability < 31 Acceptable
(Richmond et al., 1992).
Complexity grade (Pretreatment) Score range
• Hamdan and Rock suggested the PAR index over- Easy < 29
weights the overjet (weighting of 6), and under Mild 29 to 50
weights the overbite (weighting of 2) (Hamdan and
Moderate 5 1 to 63
Rock, 1999).
Difficult 64 to 77
Outcome assessment of PAR Very difficult > 77
There are three methods of assessing outcome using the PAR Improvement Grade Score Range
Index. (Pretreatment score – 4x Post-
treatment score)
• PAR score change: Reduction from pre-treatment to
post-treatment PAR score. 22-point reduction indi- Greatly improved > -1
cates great improvement. Substantially improved -25 to - l
Moderately improved -53 to -26
• PAR percentage change: Percentage change from
pre-treatment to post-treatment. A percentage im- Minimal improved -85 to -54
provement greater than 70% can be considered a Not improved or worse < -85
good standard for orthodontic treatment. 30-70%
Table 16: Interpretation of ICON scores
reduction represents an improved outcome. Less
than 30% reduction is considered to be of no im-
Traits Weighting Score 0 1 2 3 4 5
factor
Aesthetic 7 1-10 as
judged us-
ing IOTN
AC
Upper Crowding 5 Only the Less than 2.1- 5mm 5.1- 9mm 9.1-13mm 13.1- More than
arch highest 2mm 17mm 17mm or
trait either impacted
spacing or teeth
crowding
Spacing 5 Up to 2.1-5mm 5.1- 9mm More than
2mm 9mm
Crossbite 5 Transverse No cross- Cross bite
relation- bites present
ship of
cusp to
cusp or
worse
Anterior Open bite 4 Only the Complete Less than 1.1-2mm 2.1-4mm More than
highest bite 1mm 4mm
trait either
openbite
or overbite
Deep bite 4 Lower Up to 1/3 1/3- 2/3 2/3 up to Fully
incisor tooth coverage full cov- covered
coverage ered
Buccal 3 Left and Cusp to Any cusp Cusp to
segment right embrasure relation up cusp rela-
anterio- added relation- to but not tionship
posterior together ship only, including
relation- C1, C2, cusp to
ship C3 cusp
Table 17: Scoring of ICON scores
American Board of Orthodontics Discrepancy Index If there is a negative overjet (anterior crossbite), the score is
(ABO DI) recorded as 1 point per mm. per anterior tooth in crossbite.
Overjet Overbite
Overjet is scored as the distance between the incisal edge of Positive overbite is scored as follow:
the most forward positioned upper incisor and the most for-
• Overbite of up to 3 mm: 0 point are scored.
ward positioned mandibular incisor:
• Overbite between 3.1 to 5 mm: 2 points are scored.
• Overjet of 0 mm (edge to edge): 1 point.
• Overbite between 5.1 to 7 mm: 3 points are scored.
• Overjet of 0 to 3 mm: 0 point.
If the lower incisors are impinging on the palatal tissue (100%
• Overjet of 3.1 - 5 mm: 2 points.
overbite), then 5 points are scored.
Anterior openbite is scored as follow:
• If the upper and lower incisors are in an edge to edge
• Overjet over 9 mm: 5 points. relationship (overbite = 0): 1 point is scored.
Table 18: ABO DISCREPANCY INDEX
Discrepency Index
Overjet 0mm
(edge to edge) 1pt
1mm - 3mm 0 pts Occlusion
3.1 - 5mm 2 pts Class I end on 0 pt
5.1 - 7mm 3 pts End on Class II or III 2 pts perside
7.1 - 9mm 4 pts Full Class II or III 4 pts per side
>9mm 5 pts Beyond Class II or III 1 pt per mm additional
Negative OJ(x-bite) 1 pt. per mm per tooth= Total _____________
Total _______________ Lingual Posterior X Bite
Overbite 1 pt per tooth Total
0 - 3mm 0 pt Buccal Posterior X Bite
3.1 - 5 mm 2 pts 2 pts per tooth Total _______
5.1- 7mm 3 pts Cephalometrics
Impinging 100% 5 pts ANB > 5.5 or < -1.5 4pts
Total _______________ Each additional degree 1 pt
Anterior Openbite SN -GO -GN 27 degree - 37 degree 0 pt
0mm (edge to edge)= 1pt SN -GO -GN > 37 degree 2 pts per degree
then 2 pts per mm per tooth SN -GO -GN < 27 degree 1 pt per degree
Total _____________ IMPA >98 degree 1 pt. per degree
Crowding Total____________
0 - 3mm 1 pt OTHER 2 pts
3.1 - 5mm 2 pts
5.1 - 7mm 7 pts INDICATE PROBLEMS
>7mm 7 pts _________________
Total ______________ _____________
• For each millimeter of openbite, 2 points are scored
for each upper tooth involved from canine to canine. Buccal Occlusion
• No points are scored for the upper canines if they When scoring occlusion, the Angle molar classification is
are buccally displaced out of the arch. used as below:
In terms of the lateral openbite, for each upper tooth (from • If the mesiobuccal cusp of the upper first molar oc-
the first premolar to third molar) in an openbite relationship cludes with the buccal groove of the mandibular first
with the lower arch, 2 points are scored per mm of openbite molar no points are scored (this includes 1/4 unit
for each tooth. class 2 or 3).
Crowding • If the occlusal relationship is 1/2 unit class 2 or 3
(cusp to cusp), then 2 points are scored per side.
When scoring crowding the most crowded dental arch is con-
sidered. The scoring include: • If the relationship is a full class 2 or 3, then 4 points
are scored per side.
• 1 to 3 mm:1 point is scored.
• If the relationship is greater or beyond a full unit
• 3.1 - 5 mm 2 points are scored.
class 2 or 3, then 1 additional point is scored per mm
• 5.1 - 7 mm 4 points are scored. for each side.
• Greater than 7 mm: 7 points are scored.
Posterior crossbite ards to oral health from the deformity, as well as the psycho-
social effects of dentofacial aesthetics, mandibular function
In lingual posterior crossbite, for each upper posterior tooth
and speech (Salzmann, 1968). The HMAR consists of:
in lingual crossbite (from the first premolar to the third mo-
lar), 1 point is scored. In buccal posterior crossbite, for each 1. Intra-arch deviations including:
upper posterior tooth (from the first premolar to the third
• Missing teeth.
molar) in complete buccal crossbite, 2 points are scored.
• Crowding.
Cephalometric analysis
• Rotations.
If ANB angle is greater than 5.5˚ or less than -1.5˚, 4 points
are scored. For each additional degree above or below these • Spacing.
values, an additional point is scored. If the SN-Go-Gn angle
2. Inter-arch relationships including:
is between 27 ˚ to 37˚, Zero points are scored, greater than
37˚, 2 points are scored. For each additional degree above • Overjet.
37˚, 1 point is scored and for each additional degree below • Crossbite.
27˚, 1 point is scored. If the Go-Gn angle is greater than 98˚,
1 point is scored for each additional degree above 98 ˚. • Overbite.
Other variables • Openbite.
At the discretion of the examiner, an additional 2 points may • Molar and canine relationships.
be awarded for each of the following conditions: Little irregularity (LI) index
• Missing teeth (except for third molars). LI was developed by Little (Little, 1975). It assesses the ir-
• Supernumerary teeth. regularity of the lower labial segment by measuring the linear
displacement of the contact points in mm (from the mesial
• Impactions (except for third molars). contact point of the canine to the mesial contact point of the
• Ectopic eruption. canine on the contralateral side). The sum of the 5 displaced
contact points represents the relative degree of anterior ir-
• Anomalies of tooth size and shape.
regularity (Table 11). It is used in the assessment of stability
• Dental midline discrepancies greater than 3 mm. and relapse. >3.5mm of irregularity is deemed unacceptable.
• Skeletal asymmetries (involving dental compensa- The advantages of LI index are being easy to use and it pro-
tion for case completion). vides the extent of post treatment relapse of incisor crowding.
However, the disadvantages of LI index are that the index is
Advantages of ABO DI
outdated method. If two teeth are crowded and rotated, but
• Detailed/comprehensive. maintain contact point proximity, LI does not register the
crowding.
• Measures case complexity. Case complexity however
is a subjective outcome. The information can be used Crowding index
to aide decisions of who should treatment the pa-
In occlusal view, crowding is determined by measuring the
tient. The ABO DI is used for case assessment for
available horizontal space, parallel to the occlusal plane, be-
board registration in America.
tween the least displaced interproximal contact points. The
Disadvantages of ABO DI actual width of the corresponding tooth was then deducted
from the available space to give a resultant amount of crowd-
These include:
ing (positive measure) or spacing (negative measure) for each
• Complicated to perform and time consuming. tooth.
• Time-consuming. Table 19: Irregularity Index
• Relies on cephalograms and therefore irradiation for Irregularity Score
indexing.
Perfect alignment 0mm
• Reproducibility is lower than other indices.
Minimal irregularity 1-3mm
Handicapping malocclusion assessment record Moderate irregularity 4-6mm
The purpose of the HMAR is to establish a priority index for Severe irregularity 7-9mm
treatment of dentofacial deformity. The HMAR factors haz- Very severe irregularity 10mm
Maxillary expansion indices • 2= Plaque at the gingival margin (visible to the eye).
It has been stated that there is a constant relationship between • 3= Heavy plaque accumulation on tooth.
the sum of the maxillary incisor widths (SI=Sum of Incisors
It is recommended to score the buccal and lingual surfaces of
width) and the width of the maxillary arch width in an ideal
the sextants of the arch (2 surfaces per index tooth). If an in-
uncrowded dentition. This method overestimated average
dex tooth is missing, score the nearest tooth in that sextant. If
maxillary widths.
no teeth are present, record the sextant as X. If plaque thick-
The formula was then transposed to allow arch width pre- ness varies along the gingival margin, score according to the
diction: Required inter-premolar width = SI/ 0.80 Required worst situation. The overall score is the sum of the buccal and
inter-molar width = SI/0.6. lingual surfaces of the 6 teeth (12 surfaces).
McNamara proposed a simple rule of thumb indicating an Calculation of plaque index
ideal average intermolar width in males is 37 mm and in fe-
males is 36 mm. However, this proposal overestimates the
average width. Schwarz built his analysis based on the face • Plaque index for a surface of a tooth range from 0-3.
type and SI. It is considered as an accurate method for maxil-
• Plaque index for an individual tooth: Buccal and lin-
lary arch width analysis. As per Schwarz, in a narrow face, the
gual scores are added and divided by two.
inter- first premolar width is equal to SI + 6 mm while the
intermolar width is equal to SI + 12 mm. the inter- first pre- • Plaque index for a group of teeth: Scores for individ-
molar width is equal to SI + 7 mm while the intermolar width ual teeth are added and then divided by the number
is equal to SI + 14 mm. While in broad faces, the inter- first of teeth examined.
premolar width is equal to SI + 8 mm while the intermolar • Plaque index for the individual: Score for each of the
width is equal to SI + 16 mm. teeth are added and then divided by the total num-
Treatment difficulty index for unerupted maxillary ca- ber of teeth examined.
nines • Plaque index for a group of people: All indices are
The prognosis for alignment of an impacted maxillary canine taken and divided by the number of individuals.
is affected by several factors which have been listed in order • Interpretation of plaque scoring is given in Table 12.
of greatest difficulty (McSherry, 1996) (Pitt et al., 2006):
Table 20: Interpretation of Plaque index
• Horizontal position.
• Age of patient. Rating scores
0 Excellent
• Vertical height.
0.1-0.9 Good
• Bucco-palatal position.
1.0-1.9 Fair
• Angulation to midline. 2.0-3.0 Poor
• Rotation. Gingival index (GI)
• Coincidence of arch midlines. GI assesses of prevalence and severity of gingivitis. It is rec-
• Alignment and spacing of the upper labial segment. ommended to score the four surfaces of tooth no. 16, 12, 24,
36, 32 and 44.GI scores are:
• Condition of primary canine.
• 0= Healthy.
• Missing teeth.
• 1= Mild inflammation, slight change in color.
Plaque index
• 2= Moderate inflammation, redness, moderate glaz-
The plaque index was developed by Silness and Loe (Silness
ing, bleeding on pressure.
and Loe, 1964). This index is used to easily and reliably record
• 3= Severe inflammation, redness, hyperplasia, ten-
the levels of supragingival plaque. However, plaque index
dency for spontaneous bleeding.
does not indicate plaque control nor record subgingival area.
It is subjective scoring in which the plaque is scored as: Basic Periodontal Examination (BPE)
• 0= No plaque at gingival margin. BPE was developed from the Community Periodontal Index
of Treatment Needs (CPITN) (Cutress et al., 1987). BPE
• 1= Initial deposit of plaque at gingival margin (not
should be undertaken on all patients undergoing orthodon-
visible to the eye).
tic treatment. The BPE divides the dentition into 6 sextants: clination of the incisors can be corrected more easily than
anterior crossbite with normal incisor inclination) and is
• Upper right 17 to 14.
therefore more useful than a specific anomaly-score alone.
• Upper anterior 13 to 23. Advantages and disadvantages of GOSLON index are listed
in Table 19.
• Upper left 24 to 27.
Table 21: Advantages and disadvantages of GOSLON
• Lower right 47 to 44.
yardstick
• Lower anterior 43 to 33.
Advantages Disadvantages
• Lower left 34 to 37.
1.It can differentiate be- 1.The judges should be
The highest score is recorded in each sextant using WHO tween arch relationships trained in the use of this
621 probe. The probe has a ‘ball end’ 0.5 mm in diameter, and interference of facial index and recalibration is
and a black band from 3.5 to 5.5 mm. Light probing force morphology necessary to assure consis-
should be used (20-25 grams). Examination is recorded as tency
follow:
2. Good inter and intra- 2. It only scores ULCP
• Code 0 - No pockets over 3mm, no calculus and examiner reliability
overhangs and no bleeding on gentle probing. 3. It shows clinical aspects 3. Its validity has not been
• Code 1 - No pockets over 3mm, no calculus/over- in 3 planes of study. investigated
hangs but bleeding on gentle probing. 4. Differentiates between 4. It is difficult since it
• Code 2 - No pockets over 3mm but calculus / the degree of malocclusion requires a cluster of adults
plaque retentive factors and bleeding on gentle during all stages of dental with UCLP who have been
probing would be present. development treated by primary surgery
only
• Code 3 – Pocket up to 3.5-5.5mm present (black
5. It can predict surgical 5. It is less powerful than an
band of probe partially visible, indicating pocket of
outcomes at an early age of objective constant numeri-
4-5 mm).
5 years cal measurement scale
• Code 4 – Pocket >5.5 mm (black band entirely
Tooth Wear Index
within the pocket, indicating pocket of 6 mm or
more) Smith and Knight introduced the tooth wear index which
assesses tooth wear on all four visible surfaces (Smith and
• * indicates furcation involvement.
Knight, 1984). It assesses pathological tooth wear (Table
Helkimo Clinical Dysfunction (HCD) Index 16). All teeth present are scored irrespective of the aetiology
of tooth wear. The tooth wear index measures multifacto-
This epidemiological index was introduced by Van Der
rial tooth wear and distinguishes between acceptable and
Weele (van der Weele and Dibbets, 1987). It measures sever-
pathological levels of wear. However, it takes a lot of time to
ity of TMJ dysfunction, however, it gives same weight to
measure the full dentition and it is also a research tool and
all symptoms regardless whether it is muscular to articular
cannot be used without computer assistance.
disorders. Other drawback associated with this index is
that the scale of 0, 1, 5 is not continuous, the index does not Root resorption indices
indicate the severity between score numbers, hence is it not
Root resorption classification score was originally proposed
a valid nor reproducible tool. The criteria for this index are
by Malmgren (Malmgren et al., 1982) and consists of four
provided in Table 22.
grades:
GOSLON index
• Grade 1: Irregularity in the apical root contour,
The GOSLON (Great Ormond Street, London and Oslo) maintaining the original root length.
index was introduced by Mars et al.(Mars et al., 1987) as a
• Grade 2: Resorption of up to 2mm of the root length.
clinical tool to allow categorization of the dental relation-
ships (Antero-posterior, vertical and transverse relationship) • Grade 3: Resorption from 2mm up to 1/3 of the root
in 10 years old patients with unilateral cleft lip/ palate. It is length.
valuable in predicting treatment need (orthodontic treat- • Grade 4: Severe root resorption above 1/3 of the root
ment, surgical treatment). length.
GOSLON index has five discrete categories. The GOSLON •
index is treatment-linked (e.g. anterior crossbite with retro-
Table 22: Criteria for Helkimo Clinical Dysfunction Index
Symptom Criteria Score
Impaired range of movement Normal range of movement 0
Slightly impaired mobility 1
Severe impaired mobility 5
Smooth Movement without joint sounds and deviation < 2mm 0
Impaired TMJ Function Joint sounds in one or both joints and deviation > 2mm on opening or closing 1
Locking or luxation of joint 5
Muscle Pain No tenderness to palpation 0
Tenderness to palpation in 1-3 sites 1
Tenderness to palpation in 4 or more sites 5
TMJ pain No tenderness to palpation 0
Tenderness to palpation in 1-3 sites 1
Tenderness to palpation in 4 or more sites 5
Pain on movement of mandible Pain on 1 movement 0
Pain on 2 or more movements 1
No pain on movements 5
This index was modified and expanded by Alamadi and • Grade 4: Root resorption exceeding 1/3 of the root’s
team into (Alamadi et al., 2017) original length.
• Grade 1: Irregular root contour. Table 23: Tooth Wear Index
• Grade 2: less than 1/4 of the root is resorbed. Score Surface Criteria
• Grade 3: 1/4 of the root is resorbed. 0 B/L/O/I/C No loss of enamel surface
characteristics.
• Grade 4: 1/2 of the root is resorbed.
No loss of contour.
• Grade 5: 3/4 of the root is resorbed.
1 B/L/O/I/C Loss of enamel surface
• Grade 6: Middle resorption (apex of the tooth is characteristics.
maintained). Minimal loss of contour.
Another index for root resorption is the Sharpe’s index 2 B/L/O/I/C Loss of enamel leading
(Sharpe et al., 1987) which also classified root resorption to dentine exposure for
into 4 categories less than one third of the
• Grade 1: No apical root resorption. surface.
Defect less than 1 mm deep.
• Grade 2: Slight blunting of the root apex.
3 B/L/O/I/C Loss of enamel leading
• Grade 3: Moderate blunting of the root apex up to ¼ to dentine exposure for
of the root length. less than one third of the
• Grade 4: Excessive blunting of the root apex beyond surface. Loss of enamel and
the ¼ of the root length. substantial loss of dentine
Defect between 1-2 mm
Levander and colleagues (Levander et al., 1998) develop
deep.
another 4 categoriesbased index for root resorption
4 B/L/O/I/C Complete enamel loss with
• Grade 1: Irregular root contour. pulp exposure or secondary
• Grade 2: Root resorption apically, less than 2mm dentine exposure.
(Minor). Defect more than 2mm
• Grade 3: Root resorption apically, from 2mm to 1/3 deep.
of the root’s length (severe). B: Buccal; L: Lingual; O: Occlusal; I: Incisal; C: Cervical.
Maxillary suture fusion index EXAM NIGHT REVIEW
Several methods for assessment of maturation of mid-palatal ORTHODONTIC INDICES
suture are available including chronological age, dental de- An orthodontic index or malocclusion index can be defined
velopmental age, CVM staging, five stage mid-palatal suture as a means of objectively assessing occlusal status.
maturation method and hand/ wrist radiograph.
Uses of orthodontic indices
Mid-palatal suture density ratio (MSDR) by Gruntheid
(Grünheid et al., 2017) • Epidemiology
MSDR by Gruntheid is a CBCT based technique that uses • Clinical assessment
GRAY levels substitute for measuring bone density levels of • Communication
the palatal regions. Ratio value 0 refers to less calcification
of sutures while ratio value 1 refers to more calcified sutures. General characteristics of an index
In comparison to other methods MSDR shows a greater cor • Reliable.
relation with the actual measurement of skeletal expansion.
•
Reproducible: Same classification with repeated
Five stage midpalatal suture maturation method (accord- evaluations.
ing to CBCT)
• Valid: The index should measure what it was intend-
It was proposed by Angelieri (Angelieri et al., 2013). Stage 1 ed to measure.
to 3 can benefit from conventional RME, but stages 4 and 5
require surgically assisted RME (Table 21). • Universally acceptable to profession and public.
Stage 1 Straight high-density sutural line at • Requires minimal adjustment.
midline, little or no interdigitation • Simple to administer.
Stage 2 Scalloped appearance of high-den-
• Cheap.
sity sutural line at midline
Stage 3 Parallel, scalloped high density Types of indices
lines close to each other (separated • Classification indices.
in some areas by small low-density
spaces) • Diagnostic indices
Stage 4 Fusion completed in palatine bone, • Treatment assessment (need, complexity and out-
no evidence of a suture come)
Stage 5 Fusion completed anteriorly (max- • Cleft outcomes
illary region)
• Oral health indices
Index of Orthodontic Treatment Need (IOTN)
Table 24: Five stage midpalatal suture maturation method
(according to CBCT) • IOTN was developed by Brook (Brook and Shaw,
1989).
• A specific ruler had been developed aid assessment.
• IOTN has two components:
1. Dental health component (DHC).
2. Aesthetic component (AC).
Dental health component (DHC)
• This was developed based on the index treatment
priority used by the Swedish Dental Board.
• It attempts to rank malocclusion and is used as a
clinical tool to assess eligibility for NHS treatment.
• The DHC consists of 14 qualifiers and 5 grades.
• Grade 1 represents little or no need for treatment,
and grade 5 represents the great need for treatment.
Ruler is used for measurement. (Ireland et al., 2014).
• Various abbreviations used in IOTN are given in fig- Peer Assessment Rating (PAR)
ure 1.
•
This index was developed by Richmond et
• The scoring of dental health components is given in al.(Richmond et al., 1992)
figure 2.
• A total score of zero indicates good alignment, and
• Only the highest-scoring trait needs to be recorded, higher scores (rarely beyond 50) indicate significant
as this determines the grading for the patient. levels of irregularity.
• Treatment priority and need according to DHC • The difference between the pretreatment and post-
• Grades 1 and 2 represent no need for orthodontic treatment scores represent the degree of improve-
treatment ment.
• Grade 3 refers to the borderline need for treatment • There are 11 components of the PAR index:
• Grades 4 and 5 indicate definite need for treatment 1) 1. Upper anterior segment.
• It assesses few points in order as follows (MOCDO): 2) 2. Lower anterior segment.
1) 1. M - Missing teeth (5i, 5.h, 4.h) 3) 3. Upper right segment.
2) 2. O - Overjet (5.a, 4.a, 3.a, 2.a / 5.m, 4.m, 4.b, 4) 4. Upper left segment.
3.b, 2.b) 5) 5. Lower right segment.
3) 3. C - Crossbites (4.c, 3.c, 2.c) 6) 6. Lower left segment.
4) 4. D - Displacements (4.d, 3.d, 2.d) 7) 7. Right buccal occlusion.
5) 5. O - Overbite (4.f, 3.f, 2.f / 4e, 3.e, 2.e) 8) 8. Left buccal occlusion.
Aesthetic Component (AC) 9) 9. Overjet.
• The AC is a ranking system 1-10 using coloured 10) 10. Overbite.
photographs which assess dental attractiveness. The
11) 11. Centrelines.
number 1 is the most attractive, while number 10 is
the least attractive. Outcome assessment of PAR
• The grading is made by the orthodontist matching • PAR score change: Reduction from pre-treatment
the patient to AC photographs but not specific mor- to post-treatment PAR score. 22-point reduction indicates
phological similarities to the photo. great improvement.
• In the UK, a patient with a DHC of 3 or more, and • PAR percentage change: Percentage change from
an AC of 6 or more, qualify for state-funded NHS pre-treatment to post-treatment. A percentage im-
treatment. provement more significant than 70% can be con-
sidered a good standard for orthodontic treatment.
• Treatment priority and need according to the AC
30-70% reduction represents an improved outcome.
scale:
Less than 30% reduction is regarded as no improve-
• Grades 123: No/little need for treatment. ment or worse outcome.
• Grade 4: Mild need for treatment. • Graphical assessment: Assessment using a graph
• Grades 5-7: Borderline need for treatment. (nomogram).
• Grades 8-10: Definite need for orthodontic treat- Index Of Complexity Outcome & Need (ICON)
ment. • ICON was the first index based on international
An Index of Orthognathic Functional Treatment Need orthodontic opinion and was proposed by Daniels
(IOFTN) (Daniels and Richmond, 2000).
• IOFTN was developed in 2014 and prioritised se- • The index was based on the opinion of 97 interna-
vere malocclusions due to skeletal abnormalities, tional orthodontists.
not amenable to orthodontic treatment alone. It ap- • This index is comprised of an assessment of five
plies to patients who have completed facial growth traits.
• Each trait is multiplied by a weighting factor. (Minor).
• The final score is the sum of all the five trait scores. • Grade 3: Root resorption apically, from 2mm to 1/3
of the root’s length (severe).
American Board of Orthodontics Discrepancy Index
(ABO DI) • Grade 4: Root resorption exceeding 1/3 of the root’s
original length.
The traits which make up the ABO DI are:
• Overjet and anterior crossbite.
• Overbite and anterior open bite and lateral openbite.
• Crowding.
• Buccal occlusion.
• Lingual posterior crossbite and buccal posterior
crossbite.
• Cephalometric analysis: Consisting of ANB angle,
SN-Go-Gn and lower incisor to Go-Gn angle.
• An additional category designated ‘other’ is pre-
served for conditions that may affect or add to the
complexity of treatment.
Basic Periodontal Examination (BPE)
Code 0 - No pockets over 3mm, no calculus and overhangs
and no bleeding on gentle probing.
Code 1 - No pockets over 3mm, no calculus/overhangs but
bleeding on gentle probing.
Code 2 - No pockets over 3mm but calculus / plaque reten-
tive factors and bleeding on gentle probing would be pres-
ent.
Code 3 – Pocket up to 3.5-5.5mm present (black probe band
partially visible, indicating pocket of 4-5 mm).
Code 4 – Pocket >5.5 mm (black band entirely within the
pocket, indicating pocket of 6 mm or more)
* - Furcation involvement.
Root resorption indices
Malmgren’s root resorption index (Malmgren et al., 1982)
• Grade 1: Irregularity in the apical root contour,
maintaining the original root length.
• Grade 2: Resorption of up to 2mm of the root length.
• Grade 3: Resorption from 2mm to 1/3 of the root
length.
• Grade 4: Severe root resorption above 1/3 of the root
length.
Root resorption index according to Levander (Levander et
al., 1998)
• Grade 1: Irregular root contour.
• Grade 2: Root resorption apically, less than 2mm
References treatment of traumatized teeth. Am J Orthod, 82, 487-91.
Cone-beamcone-beamcone-beamALAMADI, E., ALHAZMI, H., MARS, M., PLINT, D. A., HOUSTON, W. J., BERGLAND, O. &
HANSEN, K., LUNDGREN, T. & NAOUMOVA, J. 2017. A com- SEMB, G. 1987. The Goslon Yardstick: a new system of assessing
parative study of cone beam computed tomography and conven- dental arch relationships in children with unilateral clefts of the lip
tional radiography in diagnosing the extent of root resorptions. 18, and palate. Cleft Palate J, 24, 314-22.
37.
MCCRORY, E., MCGUINNESS, N. J. & ULHAQ, A. 2018. Repro-
ANDREWS, L. F. 1972. The six keys to normal occlusion. Am J ducibility of the index of orthognathic functional treatment need
Orthod, 62, 296-309. scores derived from plaster study casts and their three-dimensional
digital equivalents: a pilot study. J Orthod, 45, 94-101.
ANGELIERI, F., CEVIDANES, L. H., FRANCHI, L., GON-
ÇALVES, J. R., BENAVIDES, E. & MCNAMARA, J. A., JR. 2013. MCSHERRY, P. F. 1996. The assessment of and treatment options
Midpalatal suture maturation: classification method for individual for the buried maxillary canine. Dent Update, 23, 7-10.
assessment before rapid maxillary expansion. Am J Orthod Dento-
ODENRICK, L., KARLANDER, O. D., EVA LILJA, PIERCE, O. D.,
facial Orthop, 144, 759-69.
ANGELA, FRACDS, O. D. & KRETSCHMAR, U. 1991. Surface
BORZABADI-FARAHANI, A., ESLAMIPOUR, F. & SHAHMO- resorption following two forms of rapid maxillary expansion. The
RADI, M. 2016. Functional needs of subjects with dentofacial European Journal of Orthodontics, 13, 264-270.
deformities: A study using the index of orthognathic functional
PITT, S., HAMDAN, A. & ROCK, P. 2006. A treatment difficulty
treatment need (IOFTN). J Plast Reconstr Aesthet Surg, 69, 796-
index for unerupted maxillary canines. Eur J Orthod, 28, 141-4.
801.
RICHMOND, S., SHAW, W. C., O’BRIEN, K. D., BUCHANAN, I.
BROOK, P. H. & SHAW, W. C. 1989. The development of an index
B., JONES, R., STEPHENS, C. D., ROBERTS, C. T. & ANDREWS,
of orthodontic treatment priority. Eur J Orthod, 11, 309-20.
M. 1992. The development of the PAR Index (Peer Assessment Rat-
CUTRESS, T. W., AINAMO, J. & SARDO-INFIRRI, J. 1987. The ing): reliability and validity. Eur J Orthod, 14, 125-39.
community periodontal index of treatment needs (CPITN) proce-
SALZMANN, J. A. 1968. Handicapping malocclusion assessment
dure for population groups and individuals. Int Dent J, 37, 222-33.
to establish treatment priority. Am J Orthod, 54, 749-65.
DANIELS, C. & RICHMOND, S. 2000. The development of the
SHARPE, W., REED, B., SUBTELNY, J. D. & POLSON, A. 1987.
index of complexity, outcome and need (ICON). J Orthod, 27,
Orthodontic relapse, apical root resorption, and crestal alveolar
149-62.
bone levels. Am J Orthod Dentofacial Orthop, 91, 252-8.
EVANS, R. & SHAW, W. 1987. Preliminary evaluation of an illus-
SILNESS, J. & LOE, H. 1964. PERIODONTAL DISEASE IN PREG-
trated scale for rating dental attractiveness. Eur J Orthod, 9, 314-8.
NANCY. II. CORRELATION BETWEEN ORAL HYGIENE AND
GRAVELY, J. F. & JOHNSON, D. B. 1974. Angle’s classification of PERIODONTAL CONDTION. Acta Odontol Scand, 22, 121-35.
malocclusion: an assessment of reliability. Br J Orthod, 1, 79-86.
SMITH, B. G. & KNIGHT, J. K. 1984. An index for measuring the
GRÜNHEID, T., LARSON, C. E. & LARSON, B. E. 2017. Midpala- wear of teeth. Br Dent J, 156, 435-8.
tal suture density ratio: A novel predictor of skeletal response to
SUMMERS, C. J. 1971. The occlusal index: a system for identifying
rapid maxillary expansion. Am J Orthod Dentofacial Orthop, 151,
and scoring occlusal disorders. Am J Orthod, 59, 552-67.
267-276.
VAN DER WEELE, L. T. & DIBBETS, J. M. 1987. Helkimo’s index:
HAMDAN, A. M. & ROCK, W. P. 1999. An appraisal of the Peer
a scale or just a set of symptoms? J Oral Rehabil, 14, 229-37.
Assessment Rating (PAR) Index and a suggested new weighting
system. Eur J Orthod, 21, 181-92. WILLIAMS, A. C. & STEPHENS, C. D. 1992. A modification to the
incisor classification of malocclusion. Br J Orthod, 19, 127-30.
HOWARD-BOWLES, E., HO, A. Y. J., ULHAQ, A. & MCGUIN-
NESS, N. J. P. 2017. The application of the Index of Orthognathic WOOLASS, K. F. & SHAW, W. C. 1987. Validity and reproducibility
Functional Treatment Need (IOFTN): service evaluation and of rating dental attractiveness from study casts. Br J Orthod, 14,
impact. J Orthod, 44, 97-104. 187-90.
IRELAND, A. J., CUNNINGHAM, S. J., PETRIE, A., COBOURNE,
M. T., ACHARYA, P., SANDY, J. R. & HUNT, N. P. 2014. An index
of orthognathic functional treatment need (IOFTN). J Orthod, 41,
77-83.
LEVANDER, E., MALMGREN, O. & STENBACK, K. 1998. Apical
root resorption during orthodontic treatment of patients with mul-
tiple aplasia: a study of maxillary incisors. Eur J Orthod, 20, 427-34.
LITTLE, R. M. 1975. The irregularity index: a quantitative score of
mandibular anterior alignment. Am J Orthod, 68, 554-63.
MALMGREN, O., GOLDSON, L., HILL, C., ORWIN, A., PETRI-
NI, L. & LUNDBERG, M. 1982. Root resorption after orthodontic
6
Orthodontic
Anchorage
Written by: Mohammed Almuzian, Haris Khan, Farhana Umer
In this Chapter
1. Intra-oral sources of OA
2. Extra-oral sources of OA
3. Terms and principles used with OA
4. Classification of OA
5. Supplementing the OA unit
6. Measuring OA loss
7. OA in three planes
8. Assessment of OA need
O rthodontic Anchorage (OA) is the resistance to un-
• Group A or maximum anchorage in which the ante-
rior teeth/ Unit retraction (active unit) moves 75%
wanted reactionary forces during the orthodontic treatment into the extraction site. In comparison, 25% of the
(Proffit et al., 2018). OA should always be planned in 3 planes remaining space is utilised by the protraction of the
of space: anterior-posterior, lateral and vertical (Naish et al., posterior teeth (anchor unit). Thus, the expectation
2015). in this type of anchorage is predominantly the re-
Intra-oral sources of OA traction of the anterior teeth.
These include: • Group B or moderate anchorage includes 50% of re-

traction of anterior teeth into the extraction site and
• Cortical alveolar bone 50% protraction of posterior teeth. Therefore, there
• Soft tissue is equal movement from both the active and anchor
units.
• Teeth
• Group C or non-critical anchorage in which the
• Occlusal interferences (Dudic et al., 2013), i.e. occlu- anterior retraction utilises 25% of the created space,
sal interference with the anchor segment increases while protraction of posterior teeth occupies 75%.
its anchorage value. Thus, a more significant movement of the anchor
• Basal bone unit is seen in this case.
• Labial musculature (OA is derived from the action • Absolute Anchorage where the posterior teeth pro-
of muscles such as a lip bumper) tract minimally (less than 1mm). Hence, posterior
teeth position is essentially maintained.
Extra-oral sources of OA
B. According to the number of teeth/type of movement in-
These include: cluding:
• Cranium • Simple OA refers to one tooth providing anchorage
• Forehead to another tooth.
• Neck • Compound OA refers to a group of teeth providing
anchorage to one tooth or a smaller number of teeth.
• Chin
• Reciprocal OA refers to an equal force applied to
Terms and principles used with OA. teeth of similar anchorage value (RSA) that causes
OA loss is the undesired movement of the anchor units equal movement towards/away from each other, for
during orthodontic treatment. OA burn (planned loss) is example, symmetrical arch expansion or closing a
performed when occlusal objectives are achieved, and the midline diastema.
aim is to close residual spaces. Each tooth’s root surface • Stationary OA is achieved by allowing the active unit
area (RSA) is proportional to its anchorage value. Greater to tip against bodily resistance of the reactive (an-
resistance has been provided with increased RSA (Hixon et chor unit)
al., 1970). However, the relationship between RSA and tooth
movement is not linear. Therefore, other factors are involved • Differential OA represents staged tooth movement
in (Pilon et al., 1996). The rate of tooth movement (RTM) to reduce anchorage demand/taxing, such as tipping
is related to force per unit RSA “differential force theory” the active unit first then uprighting it. The Differen-
(Baumrind et al., 1984). Large individual variation exists in tial force theory involves a combination of station-
the RTM for a particular force applied (Dudic et al., 2013). ary and differential OA.
Maximum RTM could be achieved with forces ranging from C. According to the source and the involved jaws, including:
104-454gm (Ren et al., 2004). RTM increases with increased
applied force, but only up to a point (Quinn and Yoshikawa, • Intraoral orthodontic anchorage such as intramaxillary
1985). and intermaxillary OA. An example of intermaxillary
OA is Class II myofunctional appliances that utilise the
Classification of OA oral muscle’s force. Another example is the intermaxillary
OA relates to all three planes of space and can be gained elastics which relies on the opposite arch to provide OA.
from intra-oral and extra-oral sources. However, prolonged use can lead to excessive extrusion,
canting the occlusal plane, and tipping the anterior teeth.
A. According to the amount of movement of the anchor unit
(Nanda and Burstone, 1993) including: • Extraoral orthodontic anchorage includes head-
gear (HG) or a protraction facemask (PFM).
72 Orthodontic Anchorage
• Soft tissue borne OA which is obtained from: 2. Bracket Type / Prescription: Standard edgewise appliances
preserve around 0.8mm of OA compared with straight wire
1. Palatal vault: OA can be obtained through contact-
appliances (SWA) in the maxillary arch; this may be due to
ing the palate and using this interaction to resist
SWA achieving greater torque and straining anchorage units
tooth movement, e.g. upper removable appliance or
than SEA (Lotzof et al., 1996). TipEdge appliances that uti-
Nance appliance.
lise the differential force theory preserve more OA (0.6mm)
2. Lip Bumper: The muscular forces of the displaced than SWA, though this is not a clinically significant (Usmani
lower lip are transferred to the molars through lip et al., 2002). Theoretically, MBT brackets are associated with
pads and heavy wire attached to the molars; this re- minimal OA due to reduced tip compared with the Roth sys-
sults in molar anchorage reinforcement, uprighting tem. Moreover, the increased molar buccal root torque in the
and distalisation. MBT prescription reinforces anchorage via the cortical bone
theory. On the other hand, some propose that lower torque
• Bone borne OA which is obtained from:
in the Roth prescription preserves OA compared with MBT.
1. Palatal arch, Nance, Lingual arch (Rebellato et al.,
3. Biomechanical factors: The use of low force magnitude
1997) generate OA by relying on the cortical an-
and archwire bends such as toe-in (1st order) and tip-back
chorage theory. Cortical anchorage theory is based
(2nd order) bends could help preserve OA. Stopped archwire
on the principle that the cortical bone resorbs slow-
such as crimpable stops mesial to the first molar and utility
er than medullary bone; therefore, a slower rate of
arches can be used to prevent mesial movement of the molar.
movement occurs when the roots of posterior teeth
However, this approach can be at the expense of the proclina-
contact cortical bone while moving buccally, hence,
tion of incisors. They are pushing mechanics that preserves
increasing OA value. However, in a clinical study, the
OA compared with pulling mechanics at the cost of procli-
palatal arch was found to have a minimal increase in
nation of the anterior segment. Theoretically, Laceback pre-
OA benefit (Zablocki et al., 2008). An RCT found
serves OA by maintaining the arch length. However, it was
no clinical significance between a palatal arch and
concluded that there are no differences in overall OA loss,
Nance appliance in terms of OA loss though patients
anterioposterior and vertical changes of the lower incisors
prefer a palatal arch over a Nance appliance (Stivaros
secondary to the use of Laceback (Irvine et al., 2004). Lace-
et al., 2010). The use of ankylosed teeth is another
backs are effective in maxillary canine retraction with sig-
example of cortical anchorage theory (Kokich et al.,
nificantly less mesial molar movement (Fleming et al., 2013).
1985)
4. Stagged tooth movement while correcting centre lines
2. Bone supported/engaged devices such as implants
by moving one active tooth at a time might minimise me-
/ miniscrews / TADs / plates can provide a direct
sial movement of the molar. Two-stage retraction includes
anchorage (Ismail and Johal, 2002). The orthodon-
retraction of canines followed by retraction of the incisors. A
tic force could be applied directly from the TAD to
systematic review confirmed that both one-stage (en-masse)
one or multiple teeth or indirectly where TAD is
and two-stage retraction are equally effective in space clo-
used to anchor one or multiple teeth in a unit; an
sure with minimal difference in AO (Sueri and Turk, 2006).
orthodontic force is then used against this anchor
unit to orthodontically move a segment. An RCT
found no clinically or statistically significant differ-
Measuring OA loss
ences in the effectiveness of 3 methods of anchorage
supplementation (TADs, Nance and HG). Hence, OA loss is assessed by comparison of tooth position relative
patient preferences should be considered (Sandler to a stable structure over time using one of the following
et al., 2014). A systematic review and meta-analysis methods:
showed moderate-quality evidence favouring mini-
1. Cephalometric analysis such as:
screw performance compared with conventional an-
chorage devices (Alharbi et al., 2018). a) Subjective (visual) cephalometric structural analy-
sis using maxillary and mandibular Bjork’s stable structures
Supplementing the OA unit
b) Objective cephalometric analysis using different
These include:
analyses such as:
1. Treatment planning related factors: For example, a plan that
• Lower incisor position about N-Pog or NB or MP:
includes utilising prosthetic implants, if possible, or modifying
the extraction pattern. Extraction of teeth close to the active unit • Pitchfork analysis in which the reference structures
is associated with less OA demand, i.e. first premolar extrac- are the maxilla and zygoma. This analysis mea-
tion instead of second premolar extraction (Naish et al., 2015). sures AP movement of the upper and lower incisors
and molars. However, there is no measurement of
Orthodontic Anchorage 73
changes in incisor inclination or canine angulation 3. Anteroposterior Orthodontic Anchorage (AP): Anchor-
(Rizk et al., 2018). age in the AP plane is reinforced with various appliances, e.g.
Nance appliance, palatal arch, headgear, upper removable ap-
• Pancherz technique measures the linear changes
pliance, or miniscrews.
from a perpendicular drawn from Sella to the occlu-
sal line. However, this method depends on maxillary Assessment of OA need
structures and the occlusal plane, which are subject
Several factors conjointly play a role in determining the OA
to change.
requirement, including:
2. The intraoral photograph is mainly a subjective visual
1. General factors include age, medical condition, individu-
technique.
al variation and patient compliance.
3. Study model measurement by superimposing 3D models
2. Treatment plan factors such as:
on the palatal rugae. This method is becoming widely used
with developments in the digital imaging (Johnston, 1996). • Treatment aims and the amount of anterior teeth re-
The palatal rugae are a reliable structure for superimposition traction compared to posterior protraction.
with a margin of error of +0.8mm (SD). Therefore, changes
• Type of movement required as the anchorage de-
less than 1.6mm are unlikely to be statistically significant
mand is high for bodily movement compared to tip-
(Sandler et al., 2014).
ping movements (Hoggan and Sadowsky, 2001).
4. Direct clinical assessment by assessing the changes in oc-
• Extraction pattern as the anchorage demand is pro-
clusal relationships, especially if one arch remains untreated
portional to the position of the extracted tooth.
as a baseline.
3. An intra-arch relationship such as:
OA in three planes
a) The involved arch, as the maxillary arch, is mainly are
Orthodontic forces are applied in vertical, transverse, and
more prone to OA loss than the mandibular arch; this is
sagittal (AP) planes. Therefore, OA requirements must be
likely due to a combination of factors:
considered in 3 dimensions.
• Maxillary anterior teeth are larger than mandibular
1. Vertical Orthodontic Anchorage: Consideration of ver-
anterior teeth, therefore, having greater root surface
tical OA is essential in treating anterior open bite and deep
area and anchorage demand when they are moved
bite. In anterior deep bite, flattening the COS involves recip-
(Zhu, 2017). Also, the surface area of the roots of
rocal OA through the extrusion of the posterior teeth and
maxillary posterior teeth (in the buccolingual direc-
intrusion of anterior teeth. The second permanent molar
tion not overall) is less than the mandibular poste-
should be bonded/banded to increase anterior intrusion.
rior teeth.
This is thought to increase the vertical OA value of the an-
chorage unit. Therefore, more significant intrusion occurs • Maxillary posterior teeth are usually upright/tipped
in the anterior segment. In an anterior open bite, adding mesially. Hence, they are more susceptible to OA
a compensatory COS in the upper arch intrudes the pos- loss (Alexandros, 2014). Also, the maxillary occlu-
terior teeth when combined with anterior intermaxillary sal plane is usually inclined clockwise with a higher
“box” elastics. This approach is referred to as ‘Kim mechan- anterior force vector than the lower occlusal plane.
ics’. Anterior elastics withstands the intrusive effects of the • The mandibular bone is denser than the maxillary
compensatory curve of Spee imparted by the wire and can bone (upper posterior is less dense than the upper
be considered a type of intermaxillary compound anchorage. anterior, lower alveolar bone is the denser bone)
2. Transverse Orthodontic Anchorage: For bilateral expan- (Geron, 2003, Devlin, 1998).
sion, there are usually an equal number of teeth on both sides, • Most prescriptions have high tip and torque built in
which achieves reciprocal OA. To accomplish a unilateral the upper anterior brackets compared to lower ante-
expansion, the anchorage side (correct side) should have a rior brackets; this is associated with high anchorage
greater number of teeth (compound anchorage), or the ex- demand.
pander is placed closer to the active unit, the side on which
expansion is required. This results in greater force on the • Individual variations (Alikhania, 2018).
active side and a lower force on the anchorage unit. While • Combination of the above.
aligning the palatally placed ectopic canines, an OA demand-
ing in 3 planes of space and mainly in the transverse plane is b) The amount of crowding as severe crowding requires
required. This can be obtained by stabilising the arch with a more OA due to multiple tooth movements.
heavy stainless steel archwire or a palatal arch. c) The location of crowding, the greater the distance be-
tween the anchor unit and the displaced active unit/teeth, EXAM NIGHT REVIEW
the greater the OA demand.
Anchorage is the resistance to unwanted reactionary forces
d) Teeth angulation, for instance, distally angulated teeth, during treatment in all three planes of space (Profit, 2000).
have a higher OA demand to align and retract than upright
Intra-oral sources of anchorage
or mesially inclined teeth due to greater root movement be-
ing required. • Cortical alveolar bone.
e) For instance, the incisors’ inclination, retroclined upper • Soft tissue.
incisor in Class II Division 2 cases, requires greater OA to
• Teeth.
torque the upper incisors.
• Basal bone.
4. The inter-arch relationship such as:
• Labial musculature in which the OA is derived from
• The degree of overbite and overjet: Increased over-
the action of muscles via a vestibular shield or lip
bite and overjet require greater OA.
bumper.
• The amount of centerline discrepancy
Extra-oral sources of anchorage
• The severity of skeletal relationship in the antero-
• Occipital.
posterior and vertical direction: It has been proven
that high angle cases have higher OA demands. This • Forehead.
is mainly because the bone in high angle cases is less • Neck.
dense than the bone in low angle cases, favouring
tooth movement and OA loss. Moreover, the orien- • Chin
tation of the occlusal plane in high angle cases fa- Classification of OA
vour the mesial movement of the anchor teeth. A
study showed that the weak muscle fibres of high A. Based on the movement of the anchor unit.
angle cases lead to low occlusal interlocking force B. According to the manner of the force application.
than low-angle cases, facilitating OA loss (Naish et
al., 2015). C. According to the source and the involved jaws.
• Buccal relationship affects occlusal interlocking; for • Intra-oral OA.

instance, cases with full unit molar relationships • Extra-oral OA.
have robust cusps to fossae interlocking relationship,
which could act as a point of resistance to OA loss Supplementing OA unit
compared to the incomplete unit cases (e.g. ½ unit Treatment planning steps to reinforce anchorage
Class II or Class III).
• The utilisation of dental implants if possible.
5. Biological factors related to the anchorage units include
the root surface area of the anchor units. For example, lower • Extraction pattern: Extraction of the teeth close to
incisors require less anchorage than canines and premolars the active unit will reduce the OA demand.
due to reduced surface area. Tooth clinical conditions and Appliance prescription
periodontal support affect OA support; for instance, peri-
• Straight-wire appliance (SWA).
odontally compromised teeth or short-rooted teeth provide
low OA support. • Tip-Edge appliance.
• MBT brackets.
Biomechanical options
• The use of toe-in (1st order) and tip-back (2nd or-
der) bends.
• The use of light forces on the active unit
• Laceback: RCT → No benefit in controlling both sag-
ittal and vertical position of lower. incisors (Alharbi
et al., 2018).
• Stopped arches (Crimpable hooks mesial to the first
molar) and utility arches.
• Pushing mechanics. • Occlusal interlocking.
• Correcting centerlines → one tooth at a time. F. Factors related to the anchorage units:
• Subdivision of the desired movement: A systematic • Root surface area of the anchor units.
review confirmed that both one step (en-masse re-
• Tooth condition and periodontal support.
traction) and two-step methods are effective for
space closure, but the one-step method with TADs
is better in anchorage reinforcement and amount of
Evidence Summary
retraction (Sueri and Turk, 2006).
• An RCT found no significant clinical difference be-
Assessment of anchorage need
tween a palatal arch (Goshgarian) and a Nance ap-
Several factors conjointly play a role in determining the OA pliance in preventing mesial drift or distal tipping.
needs, including: However, palatal arches are associated with reduced
patient discomfort (Stivaros et al., 2010).
A. General factors
• An RCT found no clinical or statistically signifi-
• Age.
cant differences in the effectiveness of 3 methods of
• Medical condition. anchorage supplementation (TADs, Nance palatal
arches and HG). Hence patients preferences should
• Medication.
be considered (Sandler et al., 2014).
• Individual variation.
• An RCT found that the use of laceback ligatures
• Patient compliance. in first premolar extraction cases doesn’t benefit
in controlling both sagittal and vertical position of
B. Treatment plan factors
lower incisors(Irvine et al., 2004).
• Treatment Aims.
• An RCT found that lacebacks do not prevent ULS
• Type of movement required (Rizk et al., 2018). proclination or molar position. The amount of ULS
• Extraction pattern. proclination depends on the angulation of the ca-
nine, and the laceback makes no difference (Usmani
C. Treatment mechanics factors et al., 2002).
• Appliance prescription: MBT has less anchorage de- • According to a systematic review and meta-analysis,
mand no evidence was found that Lacebacks effectively
• Appliance type: Tip-Edge appliance has a reduced control the sagittal position of incisors during the
anchorage demand alignment phase (Fleming et al., 2013).
• Upper removable appliance lower anchorage de- • A systematic review confirmed that both one-step
mand than a fixed appliance. and two-step retraction methods are effective for
space closure. Still, the one-step method with TAD
D. Intra-arch relationship anchorage is better in anchorage reinforcement and
• Involved arch: Maxillary arch susceptible to OA loss. the retraction (Rizk et al., 2018).
• Amount of crowding.
• Location of crowding.
• Tooth angulation.
• The inclination of the incisors
E. Inter-arch relationship
• Overbite.
• Overjet.
• Centerline discrepancy.
• A-P Skeletal relationship.
• Vertical Skeletal relationship.
References odontic Update, 8, 42-54.
ALHARBI, F., ALMUZIAN, M. & BEARN, D. 2018. Miniscrews NANDA, R. & BURSTONE, C. J. 1993. Retention and stability in
failure rate in orthodontics: systematic review and meta-analysis. orthodontics, WB Saunders company.
Eur J Orthod, 40, 519-530.
PILON, J. J., KUIJPERS-JAGTMAN, A. M. & MALTHA, J. C. 1996.
BARRER, H. 1975. Protecting the integrity of mandibular incisor Magnitude of orthodontic forces and rate of bodily tooth move-
position through keystoning procedure and spring retainer appli- ment. An experimental study. American Journal of Orthodontics
ance. Journal of clinical orthodontics: JCO, 9, 486-494. and Dentofacial Orthopedics, 110, 16-23.
BAUMRIND, S., KORN, E. L. & WEST, E. E. 1984. Prediction of PROFFIT, W. R., FIELDS, H. W., LARSON, B. & SARVER, D. M.
mandibular rotation: an empirical test of clinician performance. 2018. Contemporary orthodontics-e-book, Elsevier Health Sci-
American journal of orthodontics, 86, 371-385. ences.
BENINGTON, P. C., GARDENER, J. E. & HUNT, N. P. 1999. QUINN, R. S. & YOSHIKAWA, D. K. 1985. A reassessment of force
Masseter muscle volume measured using ultrasonography and its magnitude in orthodontics. American journal of orthodontics, 88,
relationship with facial morphology. Eur J Orthod, 21, 659-70. 252-260.
DUDIC, A., GIANNOPOULOU, C. & KILIARIDIS, S. 2013. Fac- REBELLATO, J., LINDAUER, S. J., RUBENSTEIN, L. K., ISAA-
tors related to the rate of orthodontically induced tooth movement. CSON, R. J., DAVIDOVITCH, M. & VROOM, K. 1997. Lower
American Journal of Orthodontics and Dentofacial Orthopedics, arch perimeter preservation using the lingual arch. Am J Orthod
143, 616-621. Dentofacial Orthop, 112, 449-56.
FLEMING, P. S., JOHAL, A. & PANDIS, N. 2013. The effective- REN, Y., MALTHA, J. C., VAN’T HOF, M. A. & KUIJPERS-JAG-
ness of laceback ligatures during initial orthodontic alignment: a TMAN, A. M. 2004. Optimum force magnitude for orthodontic
systematic review and meta-analysis. Eur J Orthod, 35, 539-46. tooth movement: a mathematic model. American journal of ortho-
dontics and dentofacial orthopedics, 125, 71-77.
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G.
J. 2016. Orthodontics-e-book: current principles and techniques, RIZK, M. Z., MOHAMMED, H., ISMAEL, O. & BEARN, D. R.
Elsevier Health Sciences. 2018. Effectiveness of en masse versus two-step retraction: a sys-
tematic review and meta-analysis. Prog Orthod, 18, 41.
HIXON, E., AASEN, T., ARANGO, J., CLARK, R., KLOS-
TERMAN, R., MILLER, S. & ODOM, W. 1970. On force and tooth SANDLER, J., MURRAY, A., THIRUVENKATACHARI, B., GUTI-
movement. American Journal of Orthodontics and Dentofacial ERREZ, R., SPEIGHT, P. & O’BRIEN, K. 2014. Effectiveness of 3
Orthopedics, 57, 476-489. methods of anchorage reinforcement for maximum anchorage in
adolescents: A 3-arm multicenter randomized clinical trial. Am J
HOGGAN, B. R. & SADOWSKY, C. 2001. The use of palatal rugae
Orthod Dentofacial Orthop, 146, 10-20.
for the assessment of anteroposterior tooth movements. Am J
Orthod Dentofacial Orthop, 119, 482-8. STIVAROS, N., LOWE, C., DANDY, N., DOHERTY, B. & MAN-
DALL, N. A. 2010. A randomized clinical trial to compare the
IRVINE, R., POWER, S. & MCDONALD, F. 2004. The effective-
Goshgarian and Nance palatal arch. Eur J Orthod, 32, 171-6.
ness of laceback ligatures: a randomized controlled clinical trial. J
Orthod, 31, 303-11; discussion 300. SUERI, M. Y. & TURK, T. 2006. Effectiveness of laceback ligatures
on maxillary canine retraction. Angle Orthod, 76, 1010-4.
ISMAIL, S. F. & JOHAL, A. S. 2002. The role of implants in ortho-
dontics. J Orthod, 29, 239-45. USMANI, T., O’BRIEN, K. D., WORTHINGTON, H. V., DER-
WENT, S., FOX, D., HARRISON, S., SANDLER, P. J. & MAN-
JOHNSTON, L. E., JR. 1996. Balancing the books on orthodontic
DALL, N. A. 2002. A randomized clinical trial to compare the
treatment: an integrated analysis of change. Br J Orthod, 23, 93-
effectiveness of canine lacebacks with reference to canine tip. J
102.
Orthod, 29, 281-6; discussion 277.
KOKICH, V. G., SHAPIRO, P. A., OSWALD, R., KOSKINEN-
ZABLOCKI, H. L., MCNAMARA, J. A., JR., FRANCHI, L. & BAC-
MOFFETT, L. & CLARREN, S. K. 1985. Ankylosed teeth as abut-
CETTI, T. 2008. Effect of the transpalatal arch during extraction
ments for maxillary protraction: a case report. Am J Orthod, 88,
treatment. Am J Orthod Dentofacial Orthop, 133, 852-60.
303-7.
LOTZOF, L. P., FINE, H. A. & CISNEROS, G. J. 1996. Canine
retraction: a comparison of two preadjusted bracket systems. Am J
NAISH, H. J., DUNBAR, C., ATACK, N. E., WILLIAMS, J. C.,
SANDY, J. R. & IRELAND, A. J. 2015. The control of unwanted
tooth movement—an overview of orthodontic anchorage. Orth-
7
TEMPORARY ANCHORAGE
DEVICES
Written by: Mohammed Almuzian, Haris Khan, Ahmed M. A. Mohamed, Zahid Majeed
In this Chapter
1. A brief history of TADs 15. Special features in the TADs
2. Design features of TADs 16. How to optimise the success rate of TADs?
3. Characteristics for ideal TADs 17. Post-operative instructions
4. Osseointegrating screws 18. Direct versus indirect anchorage
5. Types of osseointegrating screws 19. Bicortical anchorage
6. Mechanically retained screws 20. Complications associated with TADs
7. Design features of miniscrews 21. EXAM NIGHT REVIEW
8. Indications of TADs
9. Contraindications and limitations of TADs
10. Advantages of TADs
11. Disadvantages of TADs
12. Stability and failure of TADs
13. Factors affecting failure of TADs
14. The failure rate of TADs according to the site of
insertion
A temporary anchorage device (TAD) is temporarily fixed
• Versatile and convenient for insertion in a wide va-
riety of sites without damage to adjacent vital struc-
to the bone to enhance orthodontic anchorage. TADs are also tures (e.g. teeth)
known as temporary intraoral skeletal anchorage devices
(TISADs), ortho implants, mini-implant, microimplant (MI), • Convenient for application of orthodontic forces by
miniscrew, microscrew (MS) or orthodontic pins (Cope, J.B. a variety of means and in a variety of directions
2005). TADs provide anchorage either by supporting the Osseointegrating screws
teeth of the reactive unit (indirect anchorage) or by obviating
Osseointegration is the direct structural and functional con-
the need for the reactive unit altogether (indirect anchorage)
nection between living bone and a load-bearing artificial
(Alharbi, F., Almuzian, M., et al. 2018).
implant (Albrektsson, T., Brånemark, P.-I., et al. 1981). Os-
TADs differ from conventional dental implants, which sup- seo-integrating anchorage devices require surgical removal
port a prosthesis. Although traditional dental implants may following use. Osseointegrating screws can withstand high
be used for orthodontic anchorage, they are not considered forces and can provide absolute anchorage. However, osseo-
as temporary anchorage devices as they are not removed after integrating screws are required traumatic insertion and re-
the orthodontic treatment (Singh, K., Kumar, D., et al. 2010). moval as a surgical procedure are needed. Apart from specific
A brief history of TADs circumstances where immediate loading is feasible, there is
an increased waiting period before loading is mandatory (at
Osseointegrating titanium implants were first described in least 12 weeks) (Esposito, M., Grusovin, M.G., et al. 2013).
1969 (Branemark, P.I., Adell, R., et al. 1969). Vitalium im-
plants used to correct increased overbites were reported in Types of osseointegrating screws
1983 (Creekmore, T.D. and Eklund, M.K. 1983). In 1997 first These include:
titanium miniscrews was described by Kanomi (Kanomi, R.
1. Mid-palatal implants are usually supplied as cylin-
1997), and in 1999, the first mini-plate were used for orth-
drical implants with 4 to 6 mm (mostly 6) length (Wehrbein,
odontic purposes (Umemori, M., Sugawara, J., et al. 1999).
H., Feifel, H., et al. 1999) and 3-4 mm in diameter: (Tins-
Design features of TADs ley, D., O’Dwyer, J., et al. 2004). The mid-palatal implant is
These include: usually inserted 6 to 9 mm posterior to the incisive foramen
posterior to the interconnecting line of the first premolars
• Based on the materials used (Singh, K., Kumar, D., et (Kinner, F. and Schlegel, K.D. 2002). They are placed in the
al. 2010), this includes Biotolerant (stainless steel, chro- anterior palatal vault(Tinsley, D., O’Dwyer, J., et al. 2004).
mium-cobalt alloy), Bioinert (titanium alloy, pure tita- It is recommended to avoid midpalatal insertion in patients
nium, carbon) and Bioactive (hydroxylapatite, ceramic below 17 due to the high risk of failure as the suture is im-
oxidised aluminium). mature (Bernhart, T., Vollgruber, A., et al. 2000). Mid-pal-
• Based on diameter: The diameter usually ranges from 1.0 atal implants are used for distalization of molars, enmass
to 2.0 mm. reaching 3 to 4 mm in the palatal implants retraction of the anterior segment and protraction of poste-
(Mizrahi, E. and Mizrahi, B. 2007). rior teeth. The main advantages of mid-palatal implants are:
• Based on length: The length of a TAD refers to the length • It withstands greater orthodontic forces.
of the threaded body. They are typically available in 6, 8, • It provides almost absolute anchorage.
10, and 12 mm but range from 4 to 21 mm.
• It is placed away from the roots of teeth.
• Other design features such as thread depth, thread de-
sign, pitch (number of threads), taper (conical vs cylin- • High success rate, up to 89.5% (Schätzle, M., Män-
drical), flute (fluted vs not fluted), head design and pre- nchen, R., et al. 2009)
drilling vs self-drilling. While the disadvantages of mid-palatal implants are:
Characteristics for ideal TADs • Higher cost
These include: • Osseointegration means a need for waiting time be-
• Biocompatible fore loading and traumatic removal.
• Low cost • Risk of anterior teeth roots damage if placed too an-
teriorly.
• Acceptable for patients – no discomfort during in-
sertion, use or removal • There is a high failure rate in the mid-palatal suture
(Bernhart, T., Vollgruber, A., et al. 2000).
• Accept direct and indirect loading of force
2. Onplants are subperiosteal titanium alloy disks
80 Temporary Anchorage Devices

coated with hydroxyapatite on one side (Block, M.S. and • The mandibular basal bone
Hoffman, D.R. 1995). Onplants are flatform (coin-shaped),
• The anterior border of the mandibular ramus
2mm thick and 10 mm wide. The side facing bone is textured
and coated with a 75 ~µm thick hydroxyapatite layer. The • Symphysis (Çubuk, S., Kaya, B., et al. 2019)
other side facing soft tissue is smooth titanium alloy with an
The indications of miniplates are:
internally threaded hole at its centre into which abutments
can be placed. Onplants are usually placed in the palate or • Intrusion of molars bloc, up to 5mm, for correction
at areas with little bone. The advantages of Onplants are: of an AOB (Sugawara, J. 2014).
• Since it is not inserted into the bone, it is considered • Enmass distalization of maxillary and mandibular
less invasive and doesn’t need extra bone thickness teeth.
for insertion. • Cases where insertion of mini-screws is not feasible.
• It can be placed during various states of dental erup- • In orthognathic surgery, first cases (i.e. surgery pre-
tion to avoid damages to the unerupted and erupted cedes decompensation).
teeth.
• To achieve an orthopaedic effect, for example, pro-
• High success rate up to 82.8% (Feldmann, I. and traction of maxilla in growing patients (Bollard
Bondemark, L. 2008). miniplates) (De Clerck, E.E. and Swennen, G.R.
The disadvantages of Onplants are: 2011). The advantages of miniplate are:
• Osseointegration means a need for waiting time be- • The risk of root damage is low (Sherwood, K.H.,
fore loading and traumatic removal. Burch, J., et al. 2003).
• Expensive and not available commercially • A variety of convenient shapes and sizes are avail-
able.
• Two soft tissue surgical procedures are required, one
for placement and one for removal. • They are easily adaptable to most bony surfaces.
Mechanically retained screws • The varying shapes allow the force vector to be
brought near the occlusal plane, avoiding unwanted
Primary mechanical stability is provided by direct contact of
intrusion.
the TAD with bone. Hence, it doesn’t depend on osseointe-
gration. The advantages of mechanically retained screws are: • There is a high percentage of success up to 93% (Fin-
dik et al., 2017).
• Immediate loading is possible, i.e. same day of inser-
tion and early loading. • They have a higher load-bearing capacity than mini-
screws (Baumgaertel, S. 2014)
• No osseointegration is associated with these types of
screws. Therefore, their removal is more straightfor- The disadvantages of miniplate are:
ward. • Expensive
The disadvantages of mechanically retained screws are: • It requires postponing the orthodontic load by 2-3
• They withstand lower forces compared to osseointe- weeks for the mucosal flaps to heal (Cha, B.-K.,
gration devices Choi, D.-S., et al. 2011).
• Their insertion technique is sensitive and usually as- • Limited places for insertion
sociated with a steep learning curve. • More invasive and requires flap reflection in place-
Types of mechanically retained screws ment and retrieval.
• Miniplates are titanium miniplate with two or more • Patient discomfort associated with the placement,
screws attached to the bone (Sugawara, J. 2014). maintenance, and removal of the plates (Sherwood
They are provided in different shapes, L-, Y- or T- et al., 2003)
shaped with the long T- or L-arm emerging through • It may need another operator to install (surgeon/im-
the mucosa and providing the point of attachment plantologist).
for the traction force. Miniplates can be inserted in
different regions including: 2. Mini-screws are small bone screws placed in at-
tached gingivae, engaging with cortical and cancellous bone,
• Zygomatic buttress like temporary anchorage devices in orthodontic treatment.
• The lateral wall of the piriform aperture rim They are also called orthodontic mini-implants (OMIs),
Temporary Anchorage Devices 81

mini-screws implants (MSIs) and temporary anchorage • Immuno-compromised patients
devices (TADs). Miniscrews are made of three main parts:
• Patient with uncontrolled diabetes mellitus
• Head (various designs) to connect to orthodontic
• Patient with titanium allergy
appliances
• Patient with generalised or localised bone pathology,
• Trans-mucosal collar, that traverses the mucosa
e.g. severe osteoporosis, bisphosphonate treatment,
• Intraosseous thread radionecrosis, etc.,
The indications of miniscrews are: • Patients with poor oral hygiene or local infection.
A. Antero-posterior anchorage (Cousley, R.R. 2015a, Cous- The advantages of miniscrews are:
ley, R.R. 2015b) including:
• Safe to use
• Bodily incisor retraction and torque control
• Low cost
• Molar protraction
• Orthodontists can place them
• Molar distalization
• They usually placed under local anaesthetic
• Uprighting tipped molars
The disadvantages of miniscrews are:
B. Vertical anchorage (Cousley, R.R. 2015a, Cousley, R.R.
• Their insertion is technique sensitive
2015b) includes:
• Limited suitable sites for insertion
• Molar or posterior segment intrusion
• Potential to fracture 3%
• Anterior segment intrusion
• Damage to the vital structures, including tooth
• Traction of impacted teeth
roots. It has been reported that 21% of the inserted
C. Transverse anchorage (Cousley, R.R. 2015a, Cousley, TADs by inexperienced users had root contact com-
R.R. 2015b) includes: pared to 13% with experienced users.
• Used with expansion devices in bilateral and unilat- • Higher risk of failure: Most studies reported various
eral expansion success rates, 87% (Papageorgiou, S.N., Zogakis, I.P.,
et al. 2012) and 86.7% (Alharbi, F., Almuzian, M.,
• Assisting in midline correction
et al. 2018).
D. Other applications (Cousley, R.R. 2015a, Cousley, R.R.
Stability & failure of mini-screws
2015b) include:
A. Stability of miniscrews: Primary stability is the degree
• TAD-supported pontics for missing teeth.
of mechanical interlocking immediately following TADs
• Attachments for elastics in condylar fractures in insertion. It plays a vital role in both the implant’s short and
young patients, especially those in whom all perma- long-term success (Nienkemper, M., Wilmes, B., et al. 2014).
nent dentition has erupted. Secondary stability is a biological term related to the degree
of implant/bone integration (Breinemark, P., Adell, R., et al.
• Intermaxillary fixation In orthognathic surgery cas-
1969). Secondary stability depends on bone density, bone
es.
quality, implant topography and patient-related factors such
The contraindications and limitations of miniscrews are: as age and medical condition. Secondary stability reaches
• It is not recommended to place a mechanically-re- the maximum after 4-5 weeks following mini-screw inser-
tained screw in patients below the age of 12 (juve- tion.
nile patients) who have not completed the majority • Failure of the miniscrews: Successful miniscrews
of their skeletal growth (Kravitz, N.D. and Kusnoto, are those which remain stable (static) under nor-
B. 2007), mal orthodontic force application (e.g. 150−200 g)
• Patients who smoke. for a minimum of six months (Cousley, R.R. 2015b).
Failure in miniscrews typically manifests as either
• Patient taking bleeding disorders & anticoagulant noticeable lateral mobility or excessive peri-implant
treatment soft tissue swelling/hyperplasia. Patients rarely pres-
• Patient with endocarditis (requires antibiotic pro- ent with acute pain related to peri-implantitis. Sup-
phylaxis) (Leong, J.W., Kunzel, C., et al. 2012) pose the miniscrew appears to be clinically immo-
bile and asymptomatic after two to three months. In

that case, it is unlikely to develop problems under • Insertion speed should be below 150 rpm.
normal orthodontic loading as most failures occur
• Insertion torque (IT) should be 5 ~ 15 Ncm. IT <
within the first few months of insertion.
5 has low 1o stability while IT > 15 leads to micro-
Factors affecting failure of miniscrews cracks, pressure necrosis and decreased secondary
stability.
These include:
• Insertion forearm/ wrist rotation torque and speed
A. Patient (anatomical) factors (Cousley, R.R. 2015b)
should be minimised.
1. Somatic and general factors such as gender and age.
• Insertion angle of 60° to 70°is preferable (Wilmes,
However, no significant difference was found between genders
B., Su, Y.Y., et al. 2008).
(Mohammed, H., Wafaie, K., et al. 2018). It has also been re-
ported that adults have a higher success rate than adolescents • Loading force: immediate loading of 50 g showed
(Motoyoshi, M., Matsuoka, M., et al. 2007) due to higher levels better bone-implant contact while a load more than
of cortical thickness and density and lower rates of bone re- 200 gm doesn’t affect the primary stability (Cris-
modelling in adults (Mohammed, H., Wafaie, K., et al. 2018). mani, A.G., Bertl, M.H., et al. 2010).
2. Skeletal features: It was stated that high angle cases • Operator related factors: It has been reported that
have high failure rates than low angle cases due to a thinner 21% of the inserted TADs by inexperienced users
cortical plate in high angle cases. However, literature reported a had root contact compared to 13% with experienced
weak correlation between the failure of TADs and the vertical/ users. Furthermore, TADs inserted on the left side
sagittal relationship (Mohammed, H., Wafaie, K., et al. 2018). have better success rates due to the brushing bias of
right-handed people (Park, H.-S., Jeong, S.-H., et al.
3. Insertion site anatomy: Insertion of the minis-
2006)
crews in the area of keratinised attached gingiva is associ-
ated with a higher success rate than non-keratinized free The failure rate of miniscrews according to the site of in-
gingiva as the former prevents tissue overgrowth (Park, H.- sertion
S., Jeong, S.-H., et al. 2006). Moreover, it is recommended
In summary, insertion of TADs in (Mohammed, H., Wafaie,
to provide a minimum of 0.5 mm of TADs-root separation.
K., et al. 2018):
Contact between the miniscrew and the root induces unfa-
vourable ‘jiggling’ forces, which affect the blood supply and • The palatal sites (Mid-palatal, Paramedian and Para-
the bone remodelling (Mohammed, H., Wafaie, K., et al. palatal) has a success rate of 95.3%.
2018). Root contact occurs due to incorrect initial insertion
• The maxillary buccal sites (between teeth 6-5, be-
point, anatomical variation of root morphology and pro-
tween 3-2 and zygomatic buttress) has a success rate
gressive tooth movement after insertion (Mizrahi, E. 2016).
of 90.4%
4. Bone characteristics include cortex thickness
• The mandibular insertion sites (between teeth 6-5
and density. Regarding cortex thickness (quantity), 1−2
and 3-4) has a success rate of 87.7%.
mm depth of cortex appears ideal for primary stabil-
ity. More than 2mm leads to greater stress concentration Special features in the miniscrews
on the cortical plate. While cortex might resorb, cancel- These include:
lous bone aids in secondary stability by remodelling at the
compression side of orthodontic tooth movement. More- • Pre-drilling: Pre-drilling TADs have a blunt tip, so a
over, high cortex density (quality) results in better stability. predrilling pilot hole is required. It is recommended
for areas with high bone density and when the inser-
5. Mini-implant (design) factors such as: tion angle is oblique to prevent slippage of the screw
• Material of the TADs: Grade V machined (smooth) on insertion.
titanium alloy and stainless steel are acceptable. • Self-drilling has a sharp tip; therefore, no pre-drill-
• Type of drilling: Self-drilling performed better than ing nor pilot hole is required (Kim, J.-W., Ahn, S.-J.,
pre-drilling during the primary stability phase, but et al. 2005). The tip of these TADs is either tapered
no difference was reported regarding secondary sta- or have a notch (flute) at the end that helps in drill-
bility. ing. It has been reported that self-drilling provide
better bone screw contact and primary stability with
• Size of the TADs: 1.4 mm diameter and 6-8mm
less chance of root damages (Kim, J.-W., Ahn, S.-J.,
length are preferable option for inter radicular Tads
et al. 2005). Compared to pre-drilling, self-drilling
(Park, H.-S., Jeong, S.-H., et al. 2006).
is less expensive, require a shorter operation time,
B. Clinical (insertion and loading) factors such as produces less thermal damage & bone morbidity

with minimal patient discomfort (Kim, J.-W., Ahn, • Patient preparation for TAD insertion: The patient
S.-J., et al. 2005). is instructed to rinse with a chlorhexidine solution.
A local anaesthetic gel is applied topically. A typi-
• Self-tapping: All current miniscrews are self-tap-
cal compound anaesthetic cream comprises 20% li-
ping. Both pre-drilling and self-drilling require no
docaine, 4% tetracaine, and 2% phenylephrine. A
separate tapping of a thread. The potential confusion
small amount (e.g. 0.1−0.2 ml) of local anaesthesia
is that some authors use self-tapping as a synonym
is needed when the mucosa is thick or highly kera-
for the pre-drilling (Chen, Y., Shin, H.-I., et al. 2008).
tinised.
• Pitch is the distance between the threads of the
• A clinical technique during the insertion of the
mini-screws, and it should be about 1mm (Brinley,
mini-screw: The insertion point should be as high
C.L., Behrents, R., et al. 2009).
as possible to decrease the risk of root contact but in
• The flute is a depression made longitudinally at the the attached keratinised mucosa (Park, H.-S., Jeong,
cutting end; fluting increases the primary stability S.-H., et al. 2006). To reduce the chance of root con-
(Brinley, C.L., Behrents, R., et al. 2009) tact, it is advisable to start with 90 degrees insertion
angle; then, after penetrating the cortical bone layer,
How to optimise the success rate of miniscrews?
the insertion angle is changed to 70 degrees. Inser-
These include: tion should be stopped, and the insertion point/
• Site selection: In the maxilla, the ideal insertion sites angle is changed patient has significant discomfort
are between 6-5, 2-3, extraction space of a molar, in (indicating root approximation), there is increased
the palate and infra-zygomatic crest. In the mandi- resistance indicating root contact. If an implant fails
ble, the ideal insertion sites are between 6-5, 3-4 and at a site, a new implant with a larger length or diam-
the extraction space of a molar. It is recommended eter should be used.
to avoid the placement of a miniscrew in the mid- • Loading of the mini-screw: Immediate loading with
palatal suture as the suture may be incompletely cal- force < 200gm is associated with a high success rate
cified. The para-palatal area can be utilised to insert of the miniscrews (Costa, A., Raffainl, M., et al.
TADs in the palate’s lateral borders. This insertion 1998).
site has been widely used for intrusion purposes of
Post-operative instructions
the posterior maxillary teeth. The failure rate for the
para-palatal area was 5.5%—field (Mohammed, H., These include
Wafaie, K., et al. 2018).
• The patient should be instructed to use a chlorhexi-
• Site preparation: The root angulation should be con- dine mouthwash to rinse around the miniscrew
firmed radiographically before insertion. If a TAD twice daily for the first 5 days.
is to be placed mid-treatment and there is doubt re-
• The patient should be advised to gently brush around
garding root position from the initial OPG, a peri-
the miniscrew twice daily using a fluoride toothpaste
apical radiograph should be taken. Ideally, a space
and a small-headed toothbrush,
greater than 1.5mm should be present between the
TAD and each root (Baumgaertel, S. 2014). Clinical • The patient should avoid using an electric tooth-
techniques often involve diverging adjacent roots to brush around the miniscrew and avoid ‘fiddle’ with
increase the interproximal space before mini-screw it with your fingers or tongue!
insertion.
• Patients should be informed that the miniscrew may
• Minscrews selection according to the location: For feel slightly loose at first; however, if the miniscrew
miniscrew insertion in the alveolar bone (inter ra- becomes very loose or the brace becomes detached,
dicular), a self-drilling using the smallest size within they should contact their orthodontist immediately.
the acceptable limits is recommended. Inserting the
Direct Vs indirect anchorage
miniscrew in a dense cortical bone (e.g. buccal shelf)
requires pre-drilling along with the use of a large- Direct anchorage in which the force system extends directly
sized miniscrew. between the TAD and the dental unit to be moved. Force
systems include compression spring, tension spring, elastic
• Palatal implant placement: Bone thickness should
chain, active wire ligature etc. It is essential to consider the 3D
be measured to avoid nasal cavity perforation. Mea-
location of TADs about the centre of resistance of the tooth/
surements can be taken from CBCT or lateral ceph-
group of teeth to be moved (Ozkan, S. and Bayram, M. 2016).
alogram (Wehrbein, H., Merz, B.R., et al. 1999). A
Indirect anchorage in which the TAD stabilises the dental unit
safety margin of at least 2 mm is advised.
creates an implant-reinforced dental anchorage unit and pro-

vides absolute anchorage. The mechanics used for indirect an- collar to minimise this side effect.
chorage include incorporating rigid steel wire with cross tubes
• Local emphysema
or double tube, acid etches technique, connection with TPA/
quad helix or wire ligatures (Ozkan, S. and Bayram, M. 2016). Exam night review
The advantages of direct anchorage are that the technique re- Materials
quires simple activation, including efficient mechanics with
minimal anchorage loss and less chairside time. On the other • Biotolerant (stainless steel, chromium-cobalt alloy)
hand, the benefits of indirect anchorage are that less load on • Bioinert (titanium alloy, pure titanium, carbon)
the screw is needed, if the connection is rigid, it can with-
stand more forces, and it is considered a fail-safe mechanic. • Bioactive (hydroxylapatite, ceramic oxidised alu-
minium)
The disadvantages of direct anchorage are that greater load is
applied, which might cause mobility or loss of the screw, poor Characteristics for ideal TADs
force control. Furthermore, the mechanics are not fail-safe • Biocompatible
with less vertical control. The disadvantages of indirect an-
chorage are anchorage loss as the implant might suffer from • Low cost
unnoticed breakage. With indirect anchorage, taking support • Easy at insertion and removal
from the implant is slightly complicated and time-consuming.
• Minimal damage
Bicortical anchorage
Classification of TADS
Bicortical anchorage can increase the chances of success and
primary stability (Brettin, B.T., Grosland, N.M., et al. 2008). • Osseointegrating
To obtain bicortical anchorage, it is essential to objectively • Midpalatal implants
measure the buccolingual width of the alveolus. TAD with a
• Onplants
length equal to or slightly shorter than this length is chosen.
For bicortical anchorage, TAD is inserted from the buc- • Mechanical retention
cal side while palpating the lingual side; once the tip of the
• Miniplates
screw is palpated from the lingual, insertion is stopped, and
bicortical engagement is achieved. To avoid inflammation • Mini-screws
and patient discomfort, some recommend slightly counter-
clockwise unthreading after bicortical engagement.
Mid-palatal implants
Complications associated with TADs
• Length 4 to 6 mm (mostly 6)
These include:
• Form cylindrical
• Root trauma: If the TAD comes very close to a root, it
should be removed, and repair will occur over time. • Diameter 3 to 4 mm
However, if damage has happened to the pulp, the • Success rate: 89.5% (Schatzle et al., 2009)
chances of healing and repair are less likely (Alves Jr,
M., Baratieri, C., et al. 2013), Indications
• Implantation in the nasal or maxillary sinus • Distalization of molars
• Trauma to the nerve e.g. greater palatine, inferior • Retraction of the anterior segment
alveolar or mental • Protraction of posterior teeth
• Trauma to the blood vessel, e.g. palatine artery
• Mini-screw slippage Miniplates (Sugawara, 2014)
• Mini-screw migration Region of insertion
• Fracture of screw up to 3% (Chen, C.-H., Chang, C.- • Zygomatic buttress
S., et al. 2006)
• Piriform aperture rim
• Infection and peri-implantitis
• Mandibular basal bone
• Soft tissue coverage: It is recommended to select
miniscrews with a large head/ long trans-mucosal • Anterior border of the mandibular ramus

• Symphysis
Patient discomfort (solution: prescribe analgesics if • success rate.
required)
Success rate: 92.5% (Findik et al., 2017) to 92.7% (Schatzle et • Root contact causes failure.
al., 2009)
• Micro-bone characteristics
Indications
• Time factors: Weeks 3 and 4, primary stability re-
• Intrusion of molars duces, but after 4 weeks, stability no change.
• En-mass distalization • Cortex thickness (quantity)
• when mini-screws are not feasible 1−2 mm cortex, ideal for primary stability:
• Before decompensation, i.e. surgery, first orthogna- More than 2mm →greater stress concentration.
thic cases.
• Cortex density (quality)
• Protraction of maxilla in growing patients
Increased cortical density→ stability
Mini-screws
Mini-implant (design) factors
Success rate: 87% (Papageorgious et al., 2012) and 86.7%
• Material of the TADs: Grade V machined (smooth)
(Alharbi et al., 2018).
titanium alloy and stainless steel are both acceptable
Indications;
• Type of drilling: Self-drilling performed better than
E. Antero-posterior anchorage : pre-drilling during the primary stability phase, but
no difference was reported regarding secondary sta-
• Bodily incisor retraction and torque control
bility
• Molar protraction
• Size of the TADs: 1.4 mm diameter, 6-8mm length
• Molar distalization are preferable (Crismani et al., 2010; Park et al.,
2006; Suzuki et al., 2013)
• Uprighting tipped molars
Clinical (insertion and loading) factors
F. Vertical anchorage
• Insertion speed should be below 150 rpm.
• Molar or posterior segment intrusion
• Insertion torque (IT) should be 5 ~ 15 Ncm.
• Anterior segment intrusion
• IT < 5 has low 1o stability,
• Traction of impacted teeth
• IT > 15 leads to micro-cracks, pressure necrosis and
G. Transverse anchorage
decreased 2o stability.
• Bilateral/unilateral expansion
• Insertion angle b/w 60° to 70°is preferable (Wilmes,
• Midline correction B., Su, Y.Y., et al. 2008)
H. Other applications: • Loading force: immediate loading of 50 g showed
• TAD-supported pontics. better bone-implant contact.
• Attachments for elastics. Other factors
• Intermaxillary fixation In orthognathic surgery • Operator experience: Inexperienced users mean

high chance of root contact
Factors affecting failure of mini-implants (Cousley , 2015a)
• Dominant hand side: left side → better success
Somatic and general factors
• Sex: No significant difference b/w genders
The failure rate of mini-screws according to the site of inser-
• Age: Adults lower success rate. tion (Mohammed et al., 2018)
• Skeletal features: High angle cases have high failure • Palatal sites (Mid-palatal, Paramedian and Para-
rates. palatal): 95.3%.
Insertion site anatomy • Maxillary buccal sites (b/w 6-5, b/w 3-2 and zygo-
• Soft tissue: insertion in keratinised gingiva → higher matic buttress): 90.4%.

• Mandibular insertion sites (b/w 6-5 and b/w 3-4): References
87.7%. Albrektsson, T., Brånemark, P.I., Hansson, H.A., Lindström,
Advantages of self-drilling J., 1981. Osseointegrated titanium implants. Requirements
for ensuring a long-lasting, direct bone-to-implant anchor-
• No drills required age in man. Acta Orthop. Scand. 52, 155–170. https://doi.
org/10.3109/17453678108991776
• Better bone screw contact and primary stability
Alharbi, F., Almuzian, M., Bearn, D., 2018. Miniscrews failure
• Fewer root damages rate in orthodontics: systematic review and meta-analysis. Eur. J.
• Less expensive Orthod. 40, 519–530. https://doi.org/10.1093/ejo/cjx093
Alharbi, F., Almuzian, M., Bearn, D., 2019. Anchorage effectiveness
• Decrease in operation time
of orthodontic miniscrews compared to headgear and transpalatal
• Little bone debris arches: a systematic review and meta-analysis. ACTA Odontol.
Scand. 77, 88–98. https://doi.org/10.1080/00016357.2018.1508742
• Lesser thermal damage & bone morbidity
Alkadhimi, A., Al-Awadhi, E.A., 2018. Miniscrews for orthodontic
anchorage: a review of available systems. J. Orthod. 45, 102–114.
https://doi.org/10.1080/14653125.2018.1443873
Complications associated with TADs
Alves, M., Baratieri, C., Mattos, C.T., Araújo, M.T. de S., Maia, L.C.,
• Root trauma 2013. Root repair after contact with mini-implants: systematic
• Implantation in the nasal or maxillary sinus review of the literature. Eur. J. Orthod. 35, 491–499. https://doi.
org/10.1093/ejo/cjs025
• Trauma of nerve or vessel.
Barros, S.E., Janson, G., Chiqueto, K., Garib, D.G., Janson, M.,
• Mini-screw slippage. 2011. Effect of mini-implant diameter on fracture risk and self-
drilling efficacy. Am. J. Orthod. Dentofacial Orthop. 140, e181–
• Infection. e192. https://doi.org/10.1016/j.ajodo.2011.06.016
• Soft tissue coverage Baumgaertel, S., 2014. Temporary skeletal anchorage devices:
• Mini-screw migration the case for miniscrews. Am. J. Orthod. Dentofac. Orthop. Off.
Publ. Am. Assoc. Orthod. Its Const. Soc. Am. Board Orthod. 145,
• 3% risk of fracture of the screw. 558–564. https://doi.org/10.1016/j.ajodo.2014.03.009
• Local emphysema Bernhart, T., Vollgruber, A., Gahleitner, A., Dörtbudak, O., Haas,
R., 2000. Alternative to the median region of the palate for place-
• Patient discomfort ment of an orthodontic implant. Clin. Oral Implants Res. 11,
595–601.
BLOCK, M. S.; HOFFMAN, D. R. A new device for absolute an-
chorage for orthodontics. Am J Orthod Dentofacial Orthop, 107, n.
3, p. 251-258, Mar 1995.
BRANEMARK, P. I.; ADELL, R.; BREINE, U.; HANSSON, B. O. et
al. Intra-osseous anchorage of dental prostheses. I. Experimental
studies. Scand J Plast Reconstr Surg, 3, n. 2, p. 81-100, 1969.
Brånemark, P.I., Adell, R., Breine, U., Hansson, B.O., Lindström, J.,
Ohlsson, A., 1969. Intra-osseous anchorage of dental prostheses.
I. Experimental studies. Scand. J. Plast. Reconstr. Surg. 3, 81–100.
https://doi.org/10.3109/02844316909036699
Brettin, B.T., Grosland, N.M., Qian, F., Southard, K.A., Stuntz,
T.D., Morgan, T.A., Marshall, S.D., Southard, T.E., 2008. Bicortical
vs monocortical orthodontic skeletal anchorage. Am. J. Orthod.
Dentofac. Orthop. Off. Publ. Am. Assoc. Orthod. Its Const. Soc.
Am. Board Orthod. 134, 625–635. https://doi.org/10.1016/j.
ajodo.2007.01.031
Brinley, C.L., Behrents, R., Kim, K.B., Condoor, S., Kyung, H.-M.,
Buschang, P.H., 2009. Pitch and longitudinal fluting effects on
the primary stability of miniscrew implants. Angle Orthod. 79,
1156–1161. https://doi.org/10.2319/103108-554R.1
Cha, B.-K., Choi, D.-S., Ngan, P., Jost-Brinkmann, P.-G., Kim,

S.-M., Jang, I., 2011. Maxillary protraction with miniplates provid- Surgical difficulties, success, and complication rates of orthodon-
ing skeletal anchorage in a growing Class III patient. Am. J. Or- tic miniplate anchorage systems: Experience with 382 miniplates.
thod. Dentofacial Orthop. 139, 99–112. https://doi.org/10.1016/j. Niger. J. Clin. Pract. 20, 512–516. https://doi.org/10.4103/1119-
ajodo.2009.06.025 3077.187320
Chen, C.-H., Chang, C.-S., Hsieh, C.-H., Tseng, Y.-C., Shen, Y.-S., KANOMI, R. Mini-implant for orthodontic anchorage. J Clin Or-
Huang, I.-Y., Yang, C.-F., Chen, C.-M., 2006. The use of microim- thod, 31, n. 11, p. 763-767, Nov 1997.
plants in orthodontic anchorage. J. ORAL Maxillofac. Surg. 64,
Kanomi, R., 1997. Mini-implant for orthodontic anchorage. J. Clin.
1209–1213. https://doi.org/10.1016/j.joms.2006.04.016
Orthod. JCO 31, 763–767.
Chen, Y., Shin, H.-I., Kyung, H.-M., 2008. Biomechanical and his-
Kim, J.-W., Ahn, S.-J., Chang, Y.-I., 2005. Histomorphometric and
tological comparison of self-drilling and self-tapping orthodontic
mechanical analyses of the drill-free screw as orthodontic anchor-
microimplants in dogs. Am. J. Orthod. Dentofac. Orthop. Off. Publ.
age. Am. J. Orthod. Dentofac. Orthop. Off. Publ. Am. Assoc. Or-
Am. Assoc. Orthod. Its Const. Soc. Am. Board Orthod. 133, 44–50.
thod. Its Const. Soc. Am. Board Orthod. 128, 190–194. https://doi.
https://doi.org/10.1016/j.ajodo.2007.01.023
org/10.1016/j.ajodo.2004.01.030
Cho, U.-H., Yu, W., Kyung, H.-M., 2009. Root Contact during
KIM, J.-W.; AHN, S.-J.; CHANG, Y.-I. Histomorphometric and me-
Drilling for Microimplant Placement. Angle Orthod. 80, 130–136.
chanical analyses of the drill-free screw as orthodontic anchorage.
https://doi.org/10.2319/011509-535.1
American Journal of Orthodontics and Dentofacial Orthopedics,
Cope, J.B., 2005. Temporary anchorage devices in orthodontics: A 128, n. 2, p. 190-194, 2005.
paradigm shift. Semin. Orthod., Temporary Anchorage Devices in
Kim, Y.H., Yang, S.-M., Kim, S., Lee, J.Y., Kim, K.E., Gianelly, A.A.,
Orthodontics 11, 3–9. https://doi.org/10.1053/j.sodo.2004.11.002
Kyung, S.-H., 2010. Midpalatal miniscrews for orthodontic anchor-
Costa, A., Raffainl, M., Melsen, B., 1998. Miniscrews as orthodontic age: Factors affecting clinical success. Am. J. Orthod. Dentofacial
anchorage: a preliminary report. Int. J. Adult Orthodon. Orthog- Orthop. 137, 66–72. https://doi.org/10.1016/j.ajodo.2007.11.036
nath. Surg. 13, 201–209.
Kravitz, N.D., Kusnoto, B., 2007. Risks and complications of orth-
Cousley, R.R., 2015. Mini-implants in contemporary orthodontics odontic miniscrews. Am. J. Orthod. Dentofac. Orthop. Off. Publ.
part 1: recent evidence on factors affecting clinical success. Orthod. Am. Assoc. Orthod. Its Const. Soc. Am. Board Orthod. 131, S43-51.
Update, a 8, 6–12. https://doi.org/10.12968/ortu.2015.8.1.6 https://doi.org/10.1016/j.ajodo.2006.04.027
Cousley, R.R.J., 2015. Mini-implants in contemporary orthodontics Leong, J.W., Kunzel, C., Cangialosi, T.J., 2012. Management of the
part 2: clinical applications and optimal biomechanics. Orthod. Up- American Heart Association’s guidelines for orthodontic treat-
date, b 8, 56–61. https://doi.org/10.12968/ortu.2015.8.2.56 ment of patients at risk for infective endocarditis. Am. J. Orthod.
Dentofacial Orthop. 142, 348–354. https://doi.org/10.1016/j.ajo-
CREEKMORE, T. D.; EKLUND, M. K. The possibility of skeletal an-
do.2012.05.002
chorage. J Clin Orthod, 17, n. 4, p. 266-269, Apr 1983.
Mizrahi, E., 2016. The Use of Miniscrews in Orthodontics: a Review
Crismani, A.G., Bertl, M.H., Celar, A.G., Bantleon, H.-P., Burstone,
of Selected Clinical Applications. Prim. Dent. J. 5, 20–27. https://doi.
C.J., 2010. Miniscrews in orthodontic treatment: review and analysis
org/10.1308/205016816820209569
of published clinical trials. Am. J. Orthod. Dentofac. Orthop. Off.
Publ. Am. Assoc. Orthod. Its Const. Soc. Am. Board Orthod. 137, Mizrahi, E., Mizrahi, B., 2007. Mini-screw implants (temporary
108–113. https://doi.org/10.1016/j.ajodo.2008.01.027 anchorage devices): orthodontic and pre-prosthetic applications. J.
Orthod. 34, 80–94. https://doi.org/10.1179/146531207225021987
Çubuk, S., Kaya, B., Şahinoğlu, Z., Ateş, U., Özçırpıcı, A.A., Uçkan,
S., 2019. Sagittal skeletal correction using symphyseal miniplate an- Mohammed, H., Wafaie, K., Rizk, M.Z., Almuzian, M., Sosly, R.,
chorage systems : Success rates and complications. J. Orofac. Orthop. Bearn, D.R., 2018. Role of anatomical sites and correlated risk fac-
Fortschritte Kieferorthopadie OrganOfficial J. Dtsch. Ges. Kieferor- tors on the survival of orthodontic miniscrew implants: a system-
thopadie 80, 9–16. https://doi.org/10.1007/s00056-018-0160-2 atic review and meta-analysis. Prog. Orthod. 19, 36. https://doi.
org/10.1186/s40510-018-0225-1
De Clerck, E.E.B., Swennen, G.R.J., 2011. Success rate of miniplate
anchorage for bone anchored maxillary protraction. Angle Orthod. Motoyoshi, M., Matsuoka, M., Shimizu, N., 2007. Application of
81, 1010–1013. https://doi.org/10.2319/012311-47.1 orthodontic mini-implants in adolescents. Int. J. Oral Maxillofac.
Surg. 36, 695–699. https://doi.org/10.1016/j.ijom.2007.03.009
Esposito, M., Grusovin, M.G., Maghaireh, H., Worthington, H.V.,
2013. Interventions for replacing missing teeth: different times for Nienkemper, M., Wilmes, B., Pauls, A., Drescher, D., 2014. Mini-
loading dental implants. Cochrane Database Syst. Rev. CD003878. implant stability at the initial healing period: a clinical pilot study.
https://doi.org/10.1002/14651858.CD003878.pub5 Angle Orthod. 84, 127–133. https://doi.org/10.2319/040813-271.1
Feldmann, I., Bondemark, L., 2008. Anchorage capacity of osseoin- Ozkan, S., Bayram, M., 2016. Comparison of direct and indirect
tegrated and conventional anchorage systems: a randomized con- skeletal anchorage systems combined with 2 canine retraction tech-
trolled trial. Am. J. Orthod. Dentofac. Orthop. Off. Publ. Am. Assoc. niques. Am. J. Orthod. Dentofac. Orthop. Off. Publ. Am. Assoc. Or-
Orthod. Its Const. Soc. Am. Board Orthod. 133, 339.e19–28. https:// thod. Its Const. Soc. Am. Board Orthod. 150, 763–770. https://doi.
doi.org/10.1016/j.ajodo.2007.08.014 org/10.1016/j.ajodo.2016.04.023
Findik, Y., Baykul, T., Esenlik, E., Turkkahraman, M.H., 2017. Papageorgiou, S.N., Zogakis, I.P., Papadopoulosc, M.A., 2012. Fail-

ure rates and associated risk factors of orthodontic miniscrew im- WEHRBEIN, H.; FEIFEL, H.; DIEDRICH, P. Palatal implant an-
plants: A meta-analysis. Am. J. Orthod. Dentofacial Orthop. 142, chorage reinforcement of posterior teeth: A prospective study. Am J
577+. https://doi.org/10.1016/j.ajodo.2012.05.016 Orthod Dentofacial Orthop, 116, n. 6, p. 678-686, Dec 1999.
Park, H.-S., Jeong, S.-H., Kwon, O.-W., 2006. Factors affecting the WEHRBEIN, H.; MERZ, B. R.; DIEDRICH, P. Palatal bone sup-
clinical success of screw implants used as orthodontic anchor- port for orthodontic implant anchorage--a clinical and radiological
age. Am. J. Orthod. Dentofac. Orthop. Off. Publ. Am. Assoc. Or- study. Eur J Orthod, 21, n. 1, p. 65-70, Feb 1999.
thod. Its Const. Soc. Am. Board Orthod. 130, 18–25. https://doi.
WILMES, B.; SU, Y. Y.; DRESCHER, D. Insertion angle impact on
org/10.1016/j.ajodo.2004.11.032
primary stability of orthodontic mini-implants. Angle Orthod, 78,
PARK, H.-S.; JEONG, S.-H.; KWON, O.-W. Factors affecting the n. 6, p. 1065-1070, Nov 2008.
clinical success of screw implants used as orthodontic anchorage.
130, n. 1, p. 18-25, 2006.
Samuels, R.H.A., Orth, D., Orth, M., 1996. A review of orthodontic
face-bow injuriesand safety equipment. Am. J. Orthod. Dentofacial
Orthop., Potential Iatrogenic Sequelae 110, 269–272. https://doi.
org/10.1016/S0889-5406(96)80010-2
Sandler, J., Murray, A., Thiruvenkatachari, B., Gutierrez, R., Speight,
P., O’Brien, K., 2014. Effectiveness of 3 methods of anchorage rein-
forcement for maximum anchorage in adolescents: A 3-arm multi-
center randomized clinical trial. Am. J. Orthod. Dentofac. Orthop.
Off. Publ. Am. Assoc. Orthod. Its Const. Soc. Am. Board Orthod.
146, 10–20. https://doi.org/10.1016/j.ajodo.2014.03.020
Schätzle, M., Männchen, R., Zwahlen, M., Lang, N.P., 2009. Survival
and failure rates of orthodontic temporary anchorage devices: a sys-
tematic review. Clin. Oral Implants Res. 20, 1351–1359. https://doi.
org/10.1111/j.1600-0501.2009.01754.x
Schlegel, K.A., Kinner, F., Schlegel, K.D., 2002. The anatomic basis
for palatal implants in orthodontics. Int. J. Adult Orthodon. Or-
thognath. Surg. 17, 133–139.
Sherwood, K.H., Burch, J., Thompson, W., 2003. Intrusion of super-
erupted molars with titanium miniplate anchorage. Angle Orthod.
73, 597–601. https://doi.org/10.1043/0003-3219(2003)073<0597:IO
SMWT>2.0.CO;2
Singh, K., Kumar, D., Jaiswal, R.K., Bansal, A., 2010. Temporary an-
chorage devices – Mini-implants. Natl. J. Maxillofac. Surg. 1, 30–34.
https://doi.org/10.4103/0975-5950.69160
Sugawara, J., 2014. Temporary skeletal anchorage devices: the case
for miniplates. Am. J. Orthod. Dentofac. Orthop. Off. Publ. Am.
Assoc. Orthod. Its Const. Soc. Am. Board Orthod. 145, 559–565.
https://doi.org/10.1016/j.ajodo.2014.03.010
Suzuki, M., Deguchi, T., Watanabe, H., Seiryu, M., Iikubo, M., Sa-
sano, T., Fujiyama, K., Takano-Yamamoto, T., 2013. Evaluation of
optimal length and insertion torque for miniscrews. Am. J. Or-
thod. Dentofac. Orthop. Off. Publ. Am. Assoc. Orthod. Its Const.
Soc. Am. Board Orthod. 144, 251–259. https://doi.org/10.1016/j.
ajodo.2013.03.021
Tinsley, D., O’Dwyer, J.J., Benson, P.E., Doyle, P.T., Sandler, J., 2004.
Orthodontic palatal implants: clinical technique. J. Orthod. 31, 3–8.
https://doi.org/10.1179/146531204225011472
Umemori, M., Sugawara, J., Mitani, H., Nagasaka, H., Kawamura,
H., 1999. Skeletal anchorage system for open-bite correction. Am. J.
Orthod. Dentofac. Orthop. Off. Publ. Am. Assoc. Orthod. Its Const.
Soc. Am. Board Orthod. 115, 166–174. https://doi.org/10.1016/
S0889-5406(Thomas Set al 1998, A.o.t.I.t.a.r.B., 25;275-282)70345-8

8
Extraction in
orthodontics
Written by: Mohammed Almuzian, Haris Khan, Aroosh Ahmed
In this Chapter
1. Why do we take teeth out? 14. Lower second molar extraction
2. Claimed advantages of the non-extraction ap 15. Upper central incisor extraction
proach 16. Upper lateral incisor extraction
3. Claimed advantages of extraction approach 17. Upper canine extraction
4. Prevalence of extractions in orthodontics 18. Upper first premolars extraction
5. Evidence about the detrimental effects of extrac 19. Upper second premolar extraction
tion
20. Upper first molar extraction
6. Extraction of primary teeth
21. Upper second molar extraction
7. Guidelines for extraction of primary teeth
22. Third molars extraction
8. Extraction of permanent teeth
9. Lower incisor extraction
10. Lower canine extraction
11. Lower first premolars extraction
12. Lower second premolars extraction
13. Lower first molar extraction
D r Wolf, the physiologist, stated that bone formation was
•
•
Less iatrogenic impact on the vertical relationship
Less iatrogenic effect on smile width
related to its stress. Dr Angle assumed that bone could sur-
round teeth and stabilise them in their new functional po-
sition. Dr Angle was convinced that the human jaw could
Claimed advantages of extraction approach
accommodate a full set of teeth in an ideal occlusion. Dr
Angle was also very preoccupied with facial aesthetics and These include:
maintaining the ideal profile, which could be gained from
• Controllable outcomes
the ideal positioning of a full complement of teeth. Calvin
S. Case criticises Dr Angle for his non-extraction approach • Improved stability
since it influences the profile (Bernstein, 1992a, Bernstein,
• Reduces the protrusive facial appearance
1992b). Around the 1930s, Charles Tweed and Raymond
Begg, both ex-pupils of Angle, were simultaneously revising • Minimal gingival recession
their therapies to include extractions after being dissatisfied • Tooth size reduction is required to compensate for a
with the extent of relapse noted in previous non-extraction dietary change.
cases. Raymond Begg abandons non-extraction due to high
relapse and accused the loss of interproximal abrasion for the Prevalence of extractions in orthodontics
need for extraction. McCaul (McCaul et al., 2001) found that extraction for orth-
odontic purposes represents 10% of overall extraction in
dentistry. Weintraub (Weintraub et al., 1989) found that the
Why do we take teeth out? actual extraction rate is 54% in all orthodontic treatments.
These include: He also found a wide variation in extractions that had no as-
sociation with the year of graduation. Bradbury (Bradbury,
• General factors like caries, periodontal problems, or
1985) surveyed the teeth extracted by orthodontists in a hos-
severe malposition
pital setting. The first premolars were the teeth most com-
• Relief of arch length discrepancy monly extracted tooth (59%), followed by the second premo-
lars (13%), first permanent molars (12%), second permanent
• Correction of incisor relationships and overjet
molars (7%), permanent canines (4%), permanent lateral in-
• For correction of overbite (flattening of the curve of cisors (3%) and the permanent central incisors (1%).
Spee requires space)
Evidence about the detrimental effects of extraction
• Reduce the fullness of the lip, e.g., Bimaxillary pro-
These include:
trusion
1. Profile: There is a long debate regarding the effects of
• Correction of midline shift of more than 4mm.
extraction on facial profiles. Several comparative studies
• Allow molar distalization (Drobocky and Smith, 1989, Luppanapornlarp and Johnston,
1993, Bishara et al., 1997, Paquette et al., 1992, Bowman and
• Management of tooth size discrepancy
Johnston, 2000) proved that extraction changes facial profile.
• Provision of anchorage provision and allow the use Other studies (Boley et al., 1998, Staggers, 1990, Rathod et
of intermaxillary elastic al., 2015, Zierhut et al., 2000) contradict these findings. A
• Interceptive orthodontic treatment systematic review (Iared et al., 2017) compared premolar ex-
traction versus non-extraction groups and found no signifi-
• Enhance stability (weak evidence) cant differences between the groups in terms of the aesthetic
Claimed advantages of the non-extraction approach outcomes. According to another systematic review (Leonardi
et al., 2010), there is a significant individual variation re-
These include: sponse, and the effects of extraction are small on facial pro-
• Less trauma to the child file. Another review (Konstantonis et al., 2018) showed that
extraction seems to affect facial profile, but the evidence is
• Ease of treatment low quality.
• Consumer demand 2. Smile width: Orthodontic treatment involving extrac-
• Short treatment duration tions has been accused of causing a larger “dark buccal cor-
ridor”, though this claim has been rejected by Johnson and
• Facial fullness gives a youthful profile Smith (Johnson and Smith, 1995) and a systematic review
• Less iatrogenic effect on TMJ (Christou et al., 2019) which concluded that extractions do
92 Extraction In Orthodontics
not affect the smile width and buccal corridors area. 7. The outcome of treatment: Ileri (Ileri et al., 2012) ret-
rospectively compared the outcome in treating Class I with
3. Vertical Dimension: Dewel (Dewel, 1967) expressed
the extraction of 4s, non-extraction, or extraction of single
worries that premolar extraction may tend to deepen the bite,
incisors. They found that the outcome measured on the PAR
cause lower incisors to tip lingually, and lead to TMD devel-
basis was better in non-extraction groups.
opment. On the other hand, Beit (Beit et al., 2017) found that
extraction results in a slight decrease in vertical dimension 8. General problems such as extra cost, pain, bleeding,
while non-extraction treatment increase vertical dimension. infection, prolonged treatment, difficulty to close spaces,
Paquette (Paquette et al., 1992) found no convincing stud- intra-oral detrimental effects like potential teeth size discrep-
ies that suggest that vertical dimension is influenced by ex- ancy
traction or non-extraction treatment. Similar findings were
Extraction of Specific teeth
reported by Alkumru (Alkumru et al., 2007). According to
a systematic review (Kouvelis et al., 2018), orthodontic treat- The factors that should be kept in mind before planning
ment with premolar extractions has minimal effect on the extraction in orthodontic cases are:
vertical dimension.
• Tooth-arch discrepancy: Overall, tooth material ex-
4. TMD: It has been suggested that removal of four premo- cess should be determined before planning extrac-
lar teeth before orthodontic treatment can be detrimental to tions in orthodontic cases.
the orthopaedic stability of the temporomandibular joint as
• Cephalometric discrepancy: Before planning ex-
a result of “over retraction” of the maxillary incisors during
traction, the orthodontist should consider the pa-
space closure, which displaces the mandible posteriorly (Far-
tient profile, which could be affected by tooth move-
rar and McCarty, 1982). On the other hand, Kim and col-
ment after extractions. Studies have shown that for
leagues (Kim et al., 2002) showed that orthodontic treatment
each 1 mm of retraction of the upper incisor, the up-
has little to do with TMDs. According to a Cochrane review
per lip could retract by up to 0.3-0.75 mm (Ramos et
(Luther et al., 2010, Luther et al., 2016), there are insufficient
al., 2005). Regarding the lower lip, for every 1 mm of
research data to base our clinical practice on the relationship
lower incisor retraction, the lower lip retracts by 0.6
of active orthodontic intervention and TMD. At present, the
mm-0.78 mm (Kusnoto and Kusnoto, 2001).
Cochrane evidence on TMD and orthodontic treatment have
been withdrawn. • Dental asymmetry: Studies have shown that max-
illary midline deviation from facial midline can be
5. Effect on the periodontium: Artun (Årtun et al., 1987)
accepted aesthetically if the difference is not remark-
showed that excessive proclination of mandibular incisors
ably great. According to research, the mean clinical
might lead to dehiscence, and the overlying gingiva will be-
threshold for acceptable dental midline deviation is
come very thin and more susceptible to recession than thick
2.2 +/- 1.5 mm (Beyer and Lindauer, 1998). Another
attached gingivae. According to a systematic review by Aziz
systematic review (Janson et al., 2011) showed that
(Aziz and Flores-Mir, 2011), there is some association be-
dental midline deviation of 2.2 mm is considered
tween appliance induced labial movement of mandibular in-
acceptable by both orthodontists and laypeople,
cisors and gingival recession in the presence of the following
whereas the axial midline angulation should be less
risk factors:
than 10°. Therefore, evaluating the midline as a sign
• A reduced free gingival margin thickness of dental asymmetry is one of the major concerns
before planning tooth extractions. Patients present-
• Inadequate plaque control
ing with severe dental midline deviation to the face
• Aggressive tooth brushing (especially in the lower arch) and arch length dis-
crepancy might require asymmetrical teeth extrac-
• Narrow mandibular symphysis
tions.
6. Stability and relapse: Some clinicians argue that extrac-
• Pathologies: Some pathologies play a crucial role in
tions minimise relapse. However, it has been shown that
defining orthodontic treatment planning. If teeth
relapse can happen equally in extraction and non-extraction
have periodontal problems, abnormal shapes, roots,
cases (Little, 1990). Paquette (Paquette et al., 1992) reported
and other pathologies, they should be included in
that the Little index in the lower labial segment at recall visits
the extraction pattern.
was 2.9 mm in the extraction group and 3.4 mm in the non-
extraction group. This difference was not significant. Hoyb- Extraction of primary teeth
jerg et al. (Hoybjerg et al., 2013) showed that using different
• When an orthodontist is dealing with enforced
retention regimes in extraction or non-extraction cases has
extraction of a deciduous tooth, a treatment plan
similar stability outcomes.
should be made whether to remove the unsavable
Extraction In Orthodontics 93
tooth, extract a contralateral tooth from the same duced overbite, increased inter-canine width, distal
arch (balance), or extract a tooth from the opposing tipping of the canines, minor crowding and tooth
arch (compensation). excess in the lower arch may justify lower incisor ex-
traction (Zhylich and Suri, 2011, Faerovig and Zach-
• Balancing extraction refers to removing a tooth from
risson, 1999).
the opposite side of the same arch; it is designed to
minimise centerline shift. Compensating extraction • Class I malocclusion with a well-aligned upper arch,
refers to removing a tooth from the opposing quad- good intercuspation in the buccal segment but local-
rant to maintain the buccal occlusion by allowing ised lower incisor crowding (Faerovig and Zachris-
molar teeth to drift forwards in unison. son, 1999). In such cases, it has been reported that
single incisor extrcation is asscoiated with reduced
Guidelines for extraction of primary teeth
treatment duration comapred to premolars extrac-
Before planning extraction of primary teeth, it is essential to tion (DiBiase et al., 2011) and reduced anchorage
undertake a thorough radiographical examination to assess demand due to the locked posterior occlusion.
the presence, position, and formation of the developing
• Class II malocclusion with full unit class II molar
permanent dentition.
relationship, increased overjet, and severe upper
• Primary incisor: Early loss of primary incisors has and lower arch crowding that need extraction. These
little effect on the developing permanent dentition, cases can be treated with upper premolar extraction
so it is unnecessary to balance or compensate for the and single lower incisor extraction. Studies suggest
loss of a primary incisor. that in such patients, the long term stability is better
than the traditional four premolars extraction (Lv et
• Primary canine: Early unilateral loss of a primary
al., 2010).
canine can result in centerlines deviation, especially
in crowding in the arch, which necessitates the need Contraindications for lower incisor extraction (Hegarty and
for balancing extraction. Hegarty, 1999)
• First Primary molar: A balancing extraction may These include:
be needed if the loss is unilateral, specifically in a
• Excessive overbite and overjet.
crowded arch. If mandibular first deciduous molars
are lost, some consideration can be given to com- • Poor buccal segment relationship.
pensating extractions in the maxillary arch to pre-
• Patients are having mesially angulated canines.
serve the buccal segment relationship.
• Poor prognosis of posterior teeth.
• Second primary molar: Balancing the loss of a pri-
mary second molar is not indicated because it has no Problems associated with lower incisor extractions
appreciable effect on the centerline. However, if they
These include:
are lost bilaterally in the upper or lower arch, it can
alter the molar relationship; hence, in these cases, • Reduced lower intercanine width.
compensating extractions may be considered. • Lower midline discripnacy due to asymmetric ex-
Extraction of permanent teeth traction.
1. Lower incisor extraction • Increases in the overbite and overjet.
Indications for lower incisor extraction • Needs for fixed appliance therapy to allow con-
trolled bodily movement of the incisors.
These include:
• Difficulty in achieving a good occlusal fit.
• Signficant tooth size discrepancy (TSD) with man-
dibular tooth size excess (Matsumoto et al., 2010). • High risk of space reopening (Dacre, 1985).
• In the presence of poor prognosis of lower incisor • Post-treatment black triangle due to loss of the in-
such as a periapical lesion, bony defects, severe gin- terdental papilla which can be managed by (a) off-
gival recession, heavy restoration, trauma, lost vi- setting the brackets adjacent to the extraction site to
tality, ectopically erupted or impacted incisor and indcue mesial tipping of the roots and (b) wire bend-
abnormal shapes and size such as macrodontia and ing or (c) root uprighting springs.
microdontia (Bahreman, 1977, Canut, 1996, Kokich • Iatrogenic TSD, hence, Bolton’s analysis is essential
and Shapiro, 1984) to be undertaken before extraction. TSD can be
• Mild Class III malocclusion combined with a re- managed by (a) performing upper IPR, (b) sawp-
ping upper canine brackets, (c) using low torque • To correct molar relationship and posterior crowd-
upper anterior brackets, (d) inverting lower incisors ing.
brackets, (e) using lower canine brackets with Roth
• Balancing extraction in cases with developmentally
prescription and (f) using Class II elastics.
missing lower second premolars.
• Extraction of a mandibular second premolar is as-
2. Lower canine extraction sociated with rapid space closure, so in theory, it has
minimal effect on profile in patients with a flat pro-
The mandibular canine is rarely extracted because it has a
file.
very good length and is functionally and aesthetically sig-
nificant. However, an extraction might be considered if it is
ectopically eruption, hypoplastic or periodontally compro-
5. Lower first molar extraction
mised with grade III mobility.
Indications for first molar extraction
These include:
3. Lower first premolars extraction
In certain orthodontic cases, extraction of lower first molar
Indications for lower first premolars extraction
is necessary, but before planning extraction of poor prog-
These include: nosis lower first molars, certain factors should be kept in
mind such as the age of the patient, inter arch relationship,
• First, premolars are the most frequently extracted
developmental status, and inclination of the second molars,
teeth in orthodontic cases because they allow bal-
presence, and condition of other teeth and angulation of the
anced posterior anchorage and help in maximum
second premolars.
retraction of anterior teeth (Bradbury 1985).
Indications of lower first molars
• In patients with Class I malocclusions with upper
and lower arch crowding. These include:
• In patients with Class II molar relationship, severe • Extensive caries or pathologies. For details, read the
lower arch crowding and decreased overjet. chapter of the first molar of poor prognosis.
• In patients with Class III molar relationship, mild • Hypoplastic molars- linked with molar incisor hy-
upper arch crowding and reverse or reduced overjet. poplasia.
• Extraction of premolars can be part of the serial ex- • Heavy restoration.
tractions plan.
• In high-angle cases.
• Contraindications for extractions
• Sometimes extraction of the lower first molar may
• These include: be prescribed to prevent the impaction of the third
molar and therefore create space for their eruption
• Risk of excessive lingual movement of lower incisors
(Bayram et al., 2009).
• Mild crowding in the lower arch
Contraindications for first molar extraction
• When other teeth also have a poor prognosis.
These include:
• Third molars are congenitally missing.
4. Lower second premolars extraction
6. Lower second molar extraction
Indications for for lower second premolars extraction
Indications for second molar extraction
These include:
These include:
• Lower premolars with hypoplasia, pathology, peri-
Lower second molars are rarely extracted for orthodontic
odontally involved or ectopically erupted.
purposes; however, in some circumstances, their extraction
• To relieve mild-moderate crowding in the lower is indicated such as:
arch.
• When they are severely displaced.
• To avoid excessive lingual movement of lower inci-
• When they have hypoplasia, they are heavily re-
sors.
stored or have a poor prognosis.
• Sometimes their extraction is undertaken to relieve • If maxillary central incisor and maxillary canine are
crowding in posterior teeth such as premolar crowd- in good contact, but lateral incisor is blocked out.
ing or if the premolar is vertically impacted in the
• Upper lateral incisor with severe hypoplasia.
line of the arch (Kenrad et al., 2011).
• Abnormalities in shape and size, such as peg-shaped
• Minimal crowding is present.
lateral incisor.
Contraindications for second molar extraction
• Root resorption due to ectopic eruption of maxillary
These include: canines.
• Third molars are developmentally absent • Severe ectopic eruption of the lateral incisor.
• Lower anterior crowding is greater than 1-2mm. • When the contralateral lateral incisor is develop-
mentally absent.
Advantages of second molar extraction (Bishara SE & Bur-
key P 1986) Contraindications for for upper lateral incisor extraction
These include: These include:
• Reduce the need to extract 3rd molar surgically. • If the crown of the canine is bulbous, than the cen-
tral incisor.
• Limit the morbidity associated with lower third
molar extraction. • When the shade of the upper canine is significantly
dark.
Disadvantages of second molar extraction
• When the gingival margin height of the maxillary
These include:
canine differs considerably from the upper central
• The third molar can erupt into an undesired posi- incisor.
tion (Gooris et al., 1990). Hence, a mechanical erup-
• In Class III incisal relationship.
tion of the third molar using fixed appliance therapy
might be required (Orton and Jones, 1987). 9. Upper canine extraction
• Much research has been conducted for the unsat- Indications for upper canine extraction
isfactory eruption of 3rd molars secondary to the
The maxillary canine is rarely extracted because it is func-
extraction of second molars with a wide range of
tionally and aesthetically significant. Here are some indica-
discrepancies ranging from 2-4% (Cryer, 1967)
tions for extraction of maxillary canine:
(Richardson and Richardson, 1993) to 20% (Dacre,
1987). • If maxillary lateral incisor and maxillary first pre-
molar are in good contact, the upper canine is se-
7. Upper central incisor extraction
verely displaced from the arch line.
Extraction of the central incisor is uncommon in orthodon-
• If the upper canine is ectopically erupted and unfa-
tics, but there are some situations where its extraction can be
vourable for alignment (sector 5, alpha angle greater
considered. Before planning its extraction, an orthodontist
than 55) in this case, its extraction is indicated.
should plan the replacement therapies for the extraction
space. In most cases, lateral incisors can be substituted in • If the maxillary canine undergoes some pathology
their place. Space can also be replaced with implant, pros- with a poor prognosis or abnormal shape.
thesis or transplant (Amos et al., 2009). The indications for
• When the patient is unwilling to consider a long
upper central incisor extraction are:
treatment time to align an impacted canine.
• Poor prognosis, including hypoplasia, caries or trau-
10. Upper first premolars extraction
ma (Bishara SE & Burkey P 1986).
Indications for upper first premolars extraction
• When the upper central incisors are malformed.
The first premolars are considered to be one of the most
• When upper central incisors have severe displace-
commonly extracted teeth in orthodontics (59% of overall
ment.
extraction for orthodontic purposes), followed by sec-
8. Upper lateral incisor extraction ond premolars (13%) and first permanent molars (19%).
The high percentage of first premolar extraction is related
Indications for upper lateral incisor extraction
to its position in the arch and the timing of its eruption.
These include: Moreover, its extraction is well accepted in treating cases
of malocclusion that include severe crowding, unilateral
agenesis, bimaxillary protrusion, convex facial profiles, and • In Class II surgical cases, extraction of upper second
large cephalometric discrepancies in borderline cases. The and lower first premolars are done to aid in decom-
benefits of first premolar extraction are that second premo- pensation of the arches.
lars easily substitute them from aesthetic and functional • In cases where lower premolar extraction is advised,
points of view. A good contact point is established between lower 8s are missing. Upper 2nd premolars are ex-
the canine and second premolar. Another advantage of first tracted to prevent extrusion of upper 7s.
premolar extraction is that good anchorage balance is easily
• If there is good interproximal contact between the
achieved.
upper first premolar and the molar, then a maxillary
The following are indications for maxillary first premolar second premolar is recommended.
extraction:
12. Upper first molar extraction
• When upper first premolar has hypoplasia, severely
Indication for upper first molar extraction
displaced, transposition cases and has a poor prog-
nosis. These include:
• The first premolar is often ideal in relieving anterior • If the upper first molar is carious, it has hypoplasia
and posterior crowding. or large restoration.
• As part of the serial extractions plan. • As compensation for the removal of the lower first
molar.
• Midline correction.
• To relieve posterior crowding.
• Correction of overjet.
13. Upper second molar extraction
• Anchorage balance.
Indications for upper second molar extraction
• Correction of incisor inclination.
These include:
• For levelling of the curve of Spee.
• To aid the distal movement of the upper buccal seg-
• For surgical decompensation. ments with extraoral traction.
11. Upper second premolar extraction • When upper second molars have a poor prognosis,
Indications for upper second premolar extraction grade III mobility or severe hypoplasia.
These include: • Extraction of the upper second molar helps third

molars to erupt in a more stable and satisfactory
• If crowding (mild anterior crowding) or overjet is position and hence accelerates their eruption and
moderate. decreases their chances of impaction (Bayram et al.,
• Extraction of an upper second premolar is preferred 2009).
over the first premolar if the aim is to minimise over Contraindications for upper second molar extraction
retraction of the labial segment. Hence, its extrac-
tion is useful with Class Ill malocclusions. These include clinical cases having heavily restored the first
molar and congenitally missing third molars, extraction of
• If there is early loss of E and the second premolar maxillary second molar is contraindicated.
has limited space to erupt and are ectopically erupt-
ed, its extraction is indicated. Third molars extraction
• If the maxillary second premolar is impacted, hypo- There is a wide range of variation in formation and calcifica-
plastic, small size, heavily restored, or poor progno- tion, crown and root morphology, eruption and presence or
sis. absence of third molars. As third molars erupt, they need to
create space in the alveolar arch, and sometimes, this process
• When the second premolar has severe displace- can lead to crowding in the anterior teeth (Almpani and
ment. Kolokitha, 2015). On the other hand, 13-15% of mandibular
• In patients who have congenitally missing second third molars are congenitally missing or become impacted.
premolars on the contralateral side, extraction is The following are some indications for the extraction of
advocated for symmetry of molar relationship. This third molars.
belief is usually not well accepted. • When they have unrestorable caries or non-treat-
able pulpal or periapical pathology. • Primary canine →To prevent centerlines deviation in
crowding which necessitate balancing extraction.
• In case severe chronic periodontal disease results in
bone loss and recurrent pericoronitis. • First Primary molar→Balancing extraction in
crowded arch. Compensating extractions in uppers
• When third molars have external or internal resorp-
to preserve the buccal relationship.
tion.
• Second primary molar→ No need for balancing ex-
• Any pathalogy of follicle including cyst or tumour.
traction, compensating extractions considered.
• When the presence of third molars prevents the
Extraction of permanent teeth
eruption of the second molar.
Indication for lower incisor extraction
• When they cause resorption of the second molars.
• Localised lower arch crowding.
• When the third molar is impeding surgery or recon-
structive jaw surgery. • Poor prognosis
• Mild Class III malocclusion combined with a re-
duced overbite
• Class I Good buccal intercuspation & LLS crowding.
• Full unit class II molars & localised LLS crowding.
Indication for lower canine extraction
Ectopically eruption, hypoplastic or periodontally compro-
EXAM NIGHT REVIEW mised with grade III mobility
Extraction in orthodontics Indication for first premolars extraction
Why do we take teeth out? • Class I malocclusions with crowding.
• General factors like caries, periodontal problems, or • Class II molar relationship, severe lower arch crowd-
sever malposition ing.
• Relief of arch length discrepancy • In patients with Class III molar relationship, mild
• Correction of incisor relationships and overjet upper crowding
• For correction of overbite (flattening of the curve of • Serial extractions

Spee requires space) Indication for second premolars extraction
• Facial aesthetic purpose by reducing the fullness of • Mild-moderate crowding in lowers
the lip, e.g., Bimaxillary protrusion
• To avoid retroclinations of LLS.
• To allow molar distalization
• To correct molar relationship and posterior crowd-
• Management of tooth size discrepancy ing.
• Provision of anchorage provision and allow the use • As for balancing extraction.
of intermaxillary elastics.
• Poor prognosis
• Interceptive orthodontic treatment
• Minimal effect on profile.
Extraction of primary teeth
Indication for the first molar extraction
• Balancing extraction →Ext. of the opposite side of
the same arch →to minimise centerline shift. • Extensive caries or pathologies
• Compensating extraction→Ext. in opposing quad- • High-angle cases.

rant to maintain the buccal occlusion. • Molar incisor hypoplasia.
• Guidelines for extraction of primary teeth • Heavy restoration.
• Primary incisor → No need of balancing/ compen- • Prevent impaction of 3rd molar.
sating extractions.
Indication for the upper central incisor extraction
• Poor prognosis (pathology/ hypoplasia/caries/trau- Indication for the upper first molar extraction
ma.
• Carious/ hypoplasia/ large restoration.
• Malformed.`
• As compensation
• Severe displacement.
• To relieve posterior crowding.
Indication for the upper lateral incisor extraction
Indication for the upper second molar extraction
• U1 & U3 in acceptable contact blocked out U2.
• To facilitate distalizatin
• Severe hypoplasia, abnormalities in shape and size.
• Grade III mobility
• Root resorption by U3
• Severe hypoplasia.
• Ectopically erupted U2
• To facilitate 3rd eruption.
• Absent contralateral U2.
Indication for the third molar extraction
Indication for the upper canine extraction
• Unrestorable caries or non-treatable pulpal or peri-
• If U2 & U4 are in good contact, the upper canine is apical pathology.
severely displaced from the arch line.
• Recurrent pericoronitis.
• U3 ectopically erupted, Sector 5, an alpha angle
• External or internal resorption.
greater than 55 in this case.
• Fracture line through 3rd molar.
• If the maxillary canine undergoes some pathology.
• Follicle including cyst or tumour.
• Unfavourable impacted / abnormal shape.
• Eruption of the second molar is prevented
• Poor prognosis.
• Causing resorption of the second molars.
• Patient unwilling for long treatment
• They are impeding surgery or reconstructive jaw
Indication for the upper first premolars extraction
surgery.
• Hypoplasia, severely displaced, transposition cases
and has a poor prognosis
• As part of serial extractions plan
• Midline correction
• Correction of overjet.
• Anchorage balance
• Correction of incisor inclination
• For levelling of the curve of Spee
• For surgical decompensation References
Indication for the upper second premolars extraction ALKUMRU, P., ERDEM, D. & ALTUG-ATAC, A. T. 2007. Evalu-
ation of changes in the vertical facial dimension with different an-
• Mild anterior crowding/ moderate overjet. chorage systems in extraction and non-extraction subjects treated
by Begg fixed appliances: a retrospective study. Eur J Orthod, 29,
• Prevents over retraction of ULS 508-16.
• Impacted U5 ALMPANI, K. & KOLOKITHA, O. E. 2015. Role of third molars in
• Hypoplastic, heavily restored or have a poor prog- orthodontics. World J Clin Cases, 3, 132-40.
nosis AMOS, M. J., DAY, P. & LITTLEWOOD, S. J. 2009. Autotransplan-
tation of teeth: an overview. Dent Update, 36, 102-4, 107-10, 113.
• Severe displacement.
ÅRTUN, J., KOKICH, V. G. & OSTERBERG, S. K. 1987. Long-
• Missing U5 on contralateral side. term effect of root proximity on periodontal health after orthodon-
• In Class II surgical cases for decompensation. tic treatment. American Journal of Orthodontics and Dentofacial
• Good contact b/w U4 & U6
AZIZ, T. & FLORES-MIR, C. 2011. A systematic review of the as- during orthodontic treatment with extraction of four first premo-
sociation between appliance-induced labial movement of mandibu- lars. Am J Orthod Dentofacial Orthop, 95, 220-30.
lar incisors and gingival recession. Australian orthodontic journal,
FAEROVIG, E. & ZACHRISSON, B. U. 1999. Effects of mandibu-
27, 33.
lar incisor extraction on anterior occlusion in adults with Class
BAHREMAN, A. A. 1977. Lower incisor extraction in orthodontic III malocclusion and reduced overbite. Am J Orthod Dentofacial
treatment. Am J Orthod, 72, 560-7. Orthop, 115, 113-24.
BAYRAM, M., OZER, M. & ARICI, S. 2009. Effects of first molar FARRAR, W. B. & MCCARTY, W. L. 1982. A clinical outline of
extraction on third molar angulation and eruption space. Oral Surg temporomandibular joint diagnosis and treatment, Normandie
Oral Med Oral Pathol Oral Radiol Endod, 107, e14-20. Study Group for TMJ Dysfunction.
BEIT, P., KONSTANTONIS, D., PAPAGIANNIS, A. & ELIADES, T. GOORIS, C. G., ARTUN, J. & JOONDEPH, D. R. 1990. Eruption
2017. Vertical skeletal changes after extraction and non-extraction of mandibular third molars after second-molar extractions: a radio-
treatment in matched class I patients identified by a discriminant graphic study. Am J Orthod Dentofacial Orthop, 98, 161-7.
analysis: cephalometric appraisal and Procrustes superimposition.
HEGARTY, D. J. & HEGARTY, M. 1999. Is lower incisor extraction
Prog Orthod, 18, 44.
treatment a compromise? Dent Update, 26, 117-22.
BERNSTEIN, L. 1992a. Edward H. Angle versus Calvin S. Case:
HOYBJERG, A. J., CURRIER, G. F. & KADIOGLU, O. 2013. Evalu-
extraction versus nonextraction. Historical revisionism. Part II.
ation of 3 retention protocols using the American Board of Ortho-
Am J Orthod Dentofacial Orthop, 102, 546-51.
dontics cast and radiograph evaluation. Am J Orthod Dentofacial
BERNSTEIN, L. 1992b. Edward H. Angle versus Calvin S. Case: Orthop, 144, 16-22.
extraction versus nonextraction. Part I. Historical revisionism. Am
IARED, W., KOGA DA SILVA, E. M., IARED, W. & RUFINO
J Orthod Dentofacial Orthop, 102, 464-70.
MACEDO, C. 2017. Esthetic perception of changes in facial profile
BEYER, J. W. & LINDAUER, S. J. 1998. Evaluation of dental mid- resulting from orthodontic treatment with extraction of premolars:
line position. Semin Orthod, 4, 146-52. A systematic review. J Am Dent Assoc, 148, 9-16.
BISHARA SE & BURKEY P 1986, S. M. E. A. R., AJO, 89;415-424. ILERI, Z., BASCIFTCI, F. A., MALKOC, S. & RAMOGLU, S. I.
2012. Comparison of the outcomes of the lower incisor extraction,
BISHARA, S. E., CUMMINS, D. M. & ZAHER, A. R. 1997. Treat-
premolar extraction and non-extraction treatments. Eur J Orthod,
ment and posttreatment changes in patients with Class II, Division
34, 681-5.
1 malocclusion after extraction and nonextraction treatment. Am J
Orthod Dentofacial Orthop, 111, 18-27. JANSON, G., BRANCO, N. C., FERNANDES, T. M., SATHLER,
R., GARIB, D. & LAURIS, J. R. 2011. Influence of orthodontic
BOLEY, J. C., PONTIER, J. P., SMITH, S. & FULBRIGHT, M. 1998.
treatment, midline position, buccal corridor and smile arc on smile
Facial changes in extraction and nonextraction patients. Angle
attractiveness. Angle Orthod, 81, 153-61.
Orthod, 68, 539-46.
JOHNSON, D. K. & SMITH, R. J. 1995. Smile esthetics after
BOWMAN, S. J. & JOHNSTON, L. E., JR. 2000. The esthetic
orthodontic treatment with and without extraction of four first
impact of extraction and nonextraction treatments on Caucasian
premolars. Am J Orthod Dentofacial Orthop, 108, 162-7.
patients. Angle Orthod, 70, 3-10.
KENRAD, J., VEDTOFTE, H., ANDREASEN, J. O., KVETNY, M.
BRADBURY, A. J. 1985. A current view on patterns of extraction
J. & KJAER, I. 2011. A retrospective overview of treatment choice
therapy in British health service orthodontics. Br Dent J, 159, 47-
and outcome in 126 cases with arrested eruption of mandibular
50.
second molars. Clin Oral Investig, 15, 81-7.
CANUT, J. A. 1996. Mandibular incisor extraction: indications and
KIM, M. R., GRABER, T. M. & VIANA, M. A. 2002. Orthodontics
long-term evaluation. Eur J Orthod, 18, 485-9.
and temporomandibular disorder: a meta-analysis. Am J Orthod
CHRISTOU, T., BETLEJ, A., ASWAD, N., OGDON, D. & KAU, C. Dentofacial Orthop, 121, 438-46.
H. 2019. Clinical effectiveness of orthodontic treatment on smile
KOKICH, V. G. & SHAPIRO, P. A. 1984. Lower incisor extraction
esthetics: a systematic review. Clin Cosmet Investig Dent, 11, 89-
in orthodontic treatment. Four clinical reports. Angle Orthod, 54,
101.
139-53.
CRYER, B. J. D. P. 1967. Third molar eruption and the effect of
KONSTANTONIS, D., VASILEIOU, D., PAPAGEORGIOU, S. N.
extraction of adjacent teeth. 17, 405-418.
& ELIADES, T. 2018. Soft tissue changes following extraction vs.
DACRE, J. T. 1985. The long term effects of one lower incisor nonextraction orthodontic fixed appliance treatment: a systematic
extraction. Eur J Orthod, 7, 136-44. review and meta-analysis. Eur J Oral Sci, 126, 167-179.
DACRE, J. T. 1987. The criteria for lower second molar extraction. KOUVELIS, G., DRITSAS, K., DOULIS, I., KLOUKOS, D. &
Br J Orthod, 14, 1-9. GKANTIDIS, N. 2018. Effect of orthodontic treatment with 4 pre-
molar extractions compared with nonextraction treatment on the
DEWEL, B. F. 1967. Serial extraction: its limitations and contrain-
vertical dimension of the face: A systematic review. Am J Orthod
dications in orthodontic treatment. Am J Orthod, 53, 904-21.
DROBOCKY, O. B. & SMITH, R. J. 1989. Changes in facial profile

KUSNOTO, J. & KUSNOTO, H. 2001. The effect of anterior tooth
retraction on lip position of orthodontically treated adult Indone-
sians. Am J Orthod Dentofacial Orthop, 120, 304-7.
LEONARDI, R., ANNUNZIATA, A., LICCIARDELLO, V. &
BARBATO, E. 2010. Soft tissue changes following the extraction of
premolars in nongrowing patients with bimaxillary protrusion. A
systematic review. Angle Orthod, 80, 211-6.
LITTLE, R. M. 1990. Stability and relapse of dental arch alignment.
Br J Orthod, 17, 235-41.
LUPPANAPORNLARP, S. & JOHNSTON, L. E., JR. 1993. The ef-
fects of premolar-extraction: a long-term comparison of outcomes
in “clear-cut” extraction and nonextraction Class II patients. Angle
Orthod, 63, 257-72.
LUTHER, F., LAYTON, S. & MCDONALD, F. 2010. Orthodontics
for treating temporomandibular joint (TMJ) disorders. Cochrane
Database Syst Rev, 7.
LUTHER, F., LAYTON, S. & MCDONALD, F. 2016. WITH-
DRAWN: Orthodontics for treating temporomandibular joint
(TMJ) disorders. Cochrane Database Syst Rev, Cd006541.
LV, T., BAI, D. & WANG, C. L. 2010. [Retrospective study of Class
II malocclusion patients with one lower incisor extraction treat-
ment]. Shanghai Kou Qiang Yi Xue, 19, 575-8.
MCCAUL, L. K., JENKINS, W. M. & KAY, E. J. 2001. The reasons
for the extraction of various tooth types in Scotland: a 15-year fol-
low up. J Dent, 29, 401-7.
ORTON, H. S. & JONES, S. P. 1987. Correction of mesially im-
pacted lower second and third molars. J Clin Orthod, 21, 176-81.
PAQUETTE, D. E., BEATTIE, J. R. & JOHNSTON, L. E., JR. 1992.
A long-term comparison of nonextraction and premolar extraction
edgewise therapy in “borderline” Class II patients. Am J Orthod
RAMOS, A. L., SAKIMA, M. T., PINTO ADOS, S. & BOW-
MAN, S. J. 2005. Upper lip changes correlated to maxillary incisor
retraction--a metallic implant study. Angle Orthod, 75, 499-505.
RATHOD, A. B., ARAUJO, E., VADEN, J. L., BEHRENTS, R. G. &
OLIVER, D. R. 2015. Extraction vs no treatment: Long-term facial
profile changes. Am J Orthod Dentofacial Orthop, 147, 596-603.
RICHARDSON, M. E. & RICHARDSON, A. 1993. Lower third
molar development subsequent to second molar extraction. Am J
STAGGERS, J. A. 1990. A comparison of results of second molar
and first premolar extraction treatment. Am J Orthod Dentofacial
Orthop, 98, 430-6.
WEINTRAUB, J. A., VIG, P. S., BROWN, C. & KOWALSKI, C.
J. 1989. The prevalence of orthodontic extractions. Am J Orthod
ZIERHUT, E. C., JOONDEPH, D. R., ARTUN, J. & LITTLE, R.
M. 2000. Long-term profile changes associated with successfully
treated extraction and nonextraction Class II Division 1 malocclu-
sions. Angle Orthod, 70, 208-19.

9
Interproximal Enamel
Reduction
Written by: Mohammed Almuzian, Haris Khan, Hassan Saeed
In this Chapter
1. Indications of IPR
2. General advice before commencing IPR procedure
3. Methods of IPR
4. Air rotor stripping (ARS)
5. Long term potential side effects of IPR
B allard first described Interproximal enamel reduction
(LR, 1980b; Peck and Peck, 1972). Prophylactic IPR can be
prescribed either during the initial alignment phase, imme-
(IPR) in 1944 (Ballard, 1944). IPR involves dental width re- diately after active orthodontic treatment or even 4-6months
duction, anatomic recontouring and protection of the mesial post-treatment (LR, 1980b).
and or distal enamel surfaces of a permanent tooth (Peck and
Peck, 1972). IPR can be performed in deciduous and perma- 4. Interceptive treatment to provide space when extractions
nent teeth. IPR is also called interdental stripping, enamel are not planned (Graber et al., 2012) or to premolarise re-
stripping, proximal reduction, reproximation, enamoplasty, tained primary second molars in cases with missing second
keystoning, enamel approximation and slenderising (Daska- premolars (Graber et al., 2012), hence, achieving Class I mo-
logiannakis, 2000; Peck and Peck, 1972; Rossouw and Tor- lar relationship (Graber et al., 2012).
torella, 2003). Keystoning refers to oblique IPR of the lower 5. Management of black triangles or interdental contact ar-
incisors to prevent rotational relapse (Daskalogiannakis, eas by moving the incisal contact point more apically (Saver,
2000). 2004).
Indications of IPR 6. Management of teeth size discrepancy: IPR can be pre-
These include: scribed to improve intermaxillary interdigitation if the
Bolton discrepancy is beyond the average (Bolton, 1962; Ros-
1. Improvement of the shape and form of teeth (Sarver, souw and Tortorella, 2003).
2011b).
7. Canine reshaping in canines substitution cases.
2. Space provision (LR, 1980b; Peck and Peck, 1975; Sheri-
dan, 1985): Theoretically, IPR can provide up to 8mm of General advice before commencing IPR procedure
space in total. IPR of the posterior segment can provide up IPR should be undertaken sequentially and should be less
to 6.4mm of space (0.8mm/contact x 8 contacts). IPR of the than 50% of interproximal enamel to reduce the risk of car-
anterior segment can provide up to 2.5mm (0.5mm/contact ies, sensitivity, discolouration, transeptal bone loss, and peri-
x 5 contacts). However, it is recommended to undertake a odontal disease (LR, 1980b). Trauma to the gingiva should be
conservative IPR of no more than 4mm (Proffit et al., 2007; avoided. Hence, 0.020-inch wires can be used to protect the
Tuverson, 1980) depending on the tooth shape and size (Tu- gingiva while performing IPR.
verson, 1980). The available spaces from the IPR can be uti-
IPR is mainly carried out from posterior to anterior and distal
lised to manage:
to mesial contact points. Moreover, IPR has limited applica-
• There is a mild degree of incisor proclination, es- tion in poor oral hygiene, tooth hypersensitivity, hypoplastic
pecially in the clear aligner therapy (Graber et al., teeth, teeth with high caries risk, small or narrow teeth and
2012)(Kravitz et al., 2008). teeth with artificial crowns/ veneers (Jarvis, 1990; Zachris-
• Shallow overbite (LR, 1980b). son et al., 2011).
• Mild increase in the overjet (Tuverson, 1980). Methods of IPR

These include:
• To allow retraction of the upper anterior segment
and eliminate the associated incisor interference 1. Air-rotor stripping (ARS) using either (Sheridan, 1985)
(Sarver, 2011a). using:
• Asymmetrical dental midlines. • Fine tungsten-carbide.
• A mild degree of crowding: Some evidence showed • Diamond burs with safe-tip to minimise enamel
that space provision via IPR is associated with short- ledging.
er treatment duration as the created space is close to
• Diamond-coated stripping discs mounted on slow
the area of need (Germec and Taner, 2008).
speed (30,000 rpm) straight, or contra-angle hand-
• Mild relapse secondary where IPR is combined with piece are called modified Tuverson technique (Tu-
a clear aligners (Ballard and Sheridan, 1996) or posi- verson, 1980; Zachrisson et al., 2011).
tioner appliance (Darendeliler, 1998).
According to a randomised clinical trial (Danesh et al., 2007)
3. Enhance stability and reduce relapse tendency: The ratio IPR should be followed by thorough polishing while oscillat-
of 88-92% and 90-95% for the width/height of upper and lowing systems (Profin, Ortho-Strips, and O-Drive D30).
er incisors, respectively, is one of the key successes for better
2. Abrasive strips (Zachrisson et al., 2011; Zhong et al., 2000)
incisor stability. Hence, conservative anterior IPR (1-2mm in
such as:
total) can help achieve this ratio, reducing contact points slip-
page and compensating growth-related arch length reduction • Handheld diamond abrasive strips held with the fin-
104 Interproximal Enamel Reduction

gers, a pair of Matthiew’s forceps or a custom saw- performed using ARS doesn’t cause sensitivity, new cari-
like handle. However, this procedure is less efficient ous lesions, root pathology/ gingival recession (Jarjoura et
than ARS (Chudasama and Sheridan, 2007). al., 2006; Zachrisson et al., 2011; Zachrisson et al., 2007) or
pulp damage (Sheridan, 1985; Zachrisson and Mjor, 1975),
• Motor-driven using a reciprocating or oscillating
mobility, tenderness to percussion, thermal sensitivity or
abrasive diamond strip of various thicknesses.
negative electric pulp testing results (Thordarson A, 1991).
Air rotor stripping (ARS) However, IPR with poor cooling might result in irreversible
pulpal damage (Zachrisson et al., 2011; Zachrisson and Mjor,
The recommended guideline for ARS include (Chudasama
1975) and subsequently pulpal inflammatory cell infiltration
and Sheridan, 2007):
(Zachrisson and Mjor, 1975). Some suggested that IPR in the
• Aligning teeth before undertaking ARS. anterior region could reduce gingival recession as the teeth
• Getting visual access to the contact points is recom- can be retracted over the basal bone (Tuverson, 1980).
mended using a coil spring or separator for 3-4 days.
• Protection of the interdental tissue using 0.020-
.030” brass, separators, or steel indicator
Exam night review
• Starting IPR from posterior to anterior segment
Interproximal Enamel Reduction
• Achieving a maximum of 0.5mm per proximal sur-
face or no more than 50% of the enamel thickness. • IPR can be performed in deciduous and permanent
teeth.
• Measure the space using a gauge.
• Ballard first described IPR in 1944 (BALLARD,
• Finish the enamel surface using tapered fissure car-
1944).
bide bur and strips to reduce rough surface (Danesh
et al., 2007). Indications of IPR
• Polish the enamel using Sof-Lex discs or smoothing • Improvement of shape and form of teeth (Sarver,
with an acid-based IPR (fine abrasive strip coated 2011b).
with 35% phosphoric acid gel) (Rossouw and Tor- • Space provision (LR, 1980b; Peck and Peck, 1975;
torella, 2003). Sheridan, 1985)
• Rinse with water spray. • Enhance stability and reduce relapse tendency (LR,
• Undertake a compensatory IPR in the opposing 1980a)
arch, if required. • Interceptive treatment (Graber et al., 2012)
• Application of desensitising agents (Jarvis, 1990) • Management of black triangles (Saver, 2004)
such as Tooth Mousse (Casein phosphopeptide-
amorphous calcium phosphate CPP-ACP), fluoride •
Management of teeth size discrepancy (Bolton,
varnish (Duraphat varnish) combined with gel/ 1962; Rossouw and Tortorella, 2003).
rinses to assist remineralisation. However, evidence • Canine reshaping in canines substitution cases.
showed that desensitising agents are not essential in
patients with good oral hygiene (Zachrisson et al., IPR has limited application in cases with (Jarvis, 1990; Zach-
2011). risson et al., 2011)
Long term potential side effects of IPR • Poor oral hygiene
IPR might increase pocket depths (0.5-1.5mm) (LR, 1980a), • Tooth hypersensitivity
lead to an insignificant decrease in the alveolar crest height • Hypoplastic teeth
(LR, 1980a) and reduces transeptal bone thickness due to
closer proximity of the adjacent roots. However, the long- • High caries risk
term effects on the health of periodontium are insignificant • Small or narrow teeth
(Årtun et al., 1987; Jarvis, 1990). It has been proven that
deep IPR might produce deep interproximal col and non- • Artificial crowns/ veneers
keratinised plaque susceptible gingivitis (Jarvis, 1990). Methods of IPR
Moreover, IPR might lead to tooth decay, colour changes, Air-rotor stripping (ARS) using either (Sheridan, 1985).
pulpal damage and sensitivity. Evidence showed that IPR
• Fine tungsten-carbide.
Interproximal Enamel Reduction 105

• Diamond-coated stripping discs (Tuverson, 1980; References
Zachrisson et al., 2011). Årtun, J., Kokich, V.G., Osterberg, S.K., 1987. Long-term effect of
root proximity on periodontal health after orthodontic treatment.
Abrasive strips (Zachrisson et al., 2011; Zhong et al., 2000).
Am. J. Orthod. Dentofacial Orthop. 91, 125-130.
•
Handheld Diamond (Chudasama and Sheridan, BALLARD, M.L.J.A.o., 1944. Assymetry in tooth size a factor in
2007). etiology, diagnosis and treatment of malocclusion. 14, 67-71.
• Motor-driven. Ballard, R., Sheridan, J.J., 1996. Air-rotor stripping with the Essix
anterior anchor. J. Clin. Orthod. 30, 371-373.
Long term potential side effects of IPR
Bolton, W.A., 1962. The clinical application of a tooth-size analysis.
• IPR doesn’t cause sensitivity, new carious lesions, Am. J. Orthod. 48, 504-529.
root pathology/ gingival recession (Jarjoura et al.,
2006; Zachrisson et al., 2011; Zachrisson et al., 2007) Chudasama, D., Sheridan, J.J., 2007. Guidelines for contemporary
air-rotor stripping. J. Clin. Orthod. 41, 315-320.
• IPR doesn’t cause sensitivity pulp damage (Sheri-
Danesh, G., Hellak, A., Lippold, C., Ziebura, T., Schafer, E., 2007.
dan, 1985; Zachrisson and Mjor, 1975)
Enamel surfaces following interproximal reduction with different
• IPR doesn’t cause mobility, tenderness to percus- methods. The Angle orthodontist 77, 1004-1010.
sion, thermal sensitivity, or negative electric pulp Darendeliler, M.A., 1998. Finishing Checklist.
testing results (Thordarson A, 1991).
Daskalogiannakis, J., 2000. Glossary of orthodontic terms, in: van
• IPR with poor cooling might result in irreversible der Linden, F., Miethke, R.R., McNamara, J.A.J. (Eds.). Quintes-
pulpal damage (Zachrisson et al., 2011; Zachrisson sence Publishing Co, Inc, Berlin.
and Mjor, 1975) Germec, D., Taner, T.U., 2008. Effects of extraction and nonextrac-
tion therapy with air-rotor stripping on facial esthetics in postado-
lescent borderline patients. Am. J. Orthod. Dentofacial Orthop.
133, 539-549.
Graber, L.W., Vanarsdall, R.L., Vig, K.W.L., 2012. Orthodontics
Current Principles and Techniques, 5 ed. Mosby Elsevier, Philadel-
phia, PA.
Jarjoura, K., Gagnon, G., Nieberg, L., 2006. Caries risk after inter-
proximal enamel reduction. Am. J. Orthod. Dentofacial Orthop.
130, 26-30.
Jarvis, R., 1990. Interproximal reduction in the molar/premolar
region: The new approach (review). Aust. Orthod. J. 11, 236-240.
Kravitz, N.D., Kusnoto, B., Agran, B., Viana, G., 2008. Influence of
attachments and interproximal reduction on the accuracy of canine
rotation with Invisalign. A prospective clinical study. The Angle
orthodontist 78, 682-687.
LR, B., 1980a. Fiberotomy and reproximation without lower
retention 9 years in retrospect: part II. The Angle orthodontist 50,
169-178.
LR, B., 1980b. Fiberotomy and reproximation without lower reten-
tion, nine years in retrospect: part I. Angle Orthod. 50, 88-97.
Peck, H., Peck, S., 1972. An index for assessing tooth shape devia-
tions as applied to the mandibular incisors. American Journal of
Orthodontics 61, 384-401.
Peck, H., Peck, S., 1975. Reproximation (enamel stripping) as an es-
sential orthodontic treatment ingredient. C.V. Mosby Co., St. Louis.
Proffit, W., Fields, H., Sarver, D., 2007. Contemporary Orthodon-
tics, 4th ed. Mosby Elsevier, St Louis, Missouri.
Rossouw, P.E., Tortorella, A., 2003. Enamel reduction procedures in
orthodontic treatment. Journal (Canadian Dental Association) 69,
378-383.
106 Interproximal Enamel Reduction

Sarver, D.M., 2011a. Enameloplasty and esthetic finishing in
orthodontics-differential diagnosis of incisor proclination-the
importance of appropriate visualization and records part 2. Journal
of Esthetic & Restorative Dentistry: Official Publication of the
American Academy of Esthetic Dentistry 23, 303-313.
Sarver, D.M., 2011b. Enameloplasty and esthetic finishing in
orthodontics-identification and treatment of microesthetic features
in orthodontics part 1. Journal of Esthetic & Restorative Dentistry:
Official Publication of the American Academy of Esthetic Dentistry
23, 296-302.
Saver, D., 2004. Principles of cosmetic dentistry in orthodontis:
Part 1. Shape and proportionality of anteiror teeth. American jour-
nal of orthodontics and dentofacial orthopedics : official publica-
tion of the American Association of Orthodontists, its constituent
societies, and the American Board of Orthodontics 126, 749-753.
Sheridan, J.J., 1985. Air-rotor stripping. Journal of clinical ortho-
dontics : JCO 19, 43-59.
Thordarson A, Z.B., Mjor IA, 1991. Remodeling of canines to the
shape of lateral incisors by grinding: A long-term clinical and
radiographic evlauiation. Am. J. Orthod. Dentofacial Orthop. 100,
123-132.
Tuverson, D.L., 1980. Anterior interocclusal relations Part I. Am. J.
Orthod. 78, 361-370.
Zachrisson, B.U., Minster, L., Ogaard, B., Birkhed, D., 2011. Dental
health assessed after interproximal enamel reduction: caries risk in
posterior teeth. Am. J. Orthod. Dentofacial Orthop. 139, 90-98.
Zachrisson, B.U., Mjor, I.A., 1975. Remodeling of teeth by grind-
ing. Am J Orthod Dentofacial Orthop 68, 545-553.
Zachrisson, B.U., Nyoygaard, L., Mobarak, K., 2007. Dental health
assessed more than 10 years after interproximal enamel reduction
of mandibular anterior teeth. Am. J. Orthod. Dentofacial Orthop.
131, 162-169.
Zhong, M., Jost-Brinkmann, P.G., Zellmann, M., Zellmann, S.,
Radlanski, R.J., 2000. Clinical evaluation of a new technique for
interdental enamel reduction. J. Orofac. Orthop. 61, 432-439.
Interproximal Enamel Reduction 107

CLASS 1 MALOCCLUSION
10
Written by: Mohammed Almuzian, Haris Khan, Zahid Majeed
In this Chapter
1. Aetiologies of Class I malocclusion
2. Extra-oral features of Class I malocclusion
3. Intra-oral features of Class I malocclusion
4. Methods of space provision to treat Class I mal-
occlusion
T he British Standard Incisor (BSI) classification is based on
lary protrusion, where lip fullness and lips can be
incompetent).
the incisor relationship, while Angle’s classification is based
on the molar relationship. Class I incisor is defined as the in- Intra-oral features of Class I malocclusion
cisal edge of the lower incisors occludes or lies immediately These include:
below the cingulum plateau of the upper incisors. (BSI, 1983).
• The common intra-oral feature is crowding, but
Class I molar is defined as the mesiobuccal cusp of the up-
spacing may also be seen.
per first permanent molar occludes in the buccal groove of
the lower first permanent molar in terms of Angle’s classifica- • Incisors are in Class I relationship, canines and mo-
tion (also termed ‘neutrocclusion’) (Angle, 1899). Andrews’s lars are usually in Class I relationship.
Class I molar relationship has two conditions: firstly, the
• Overjet is usually normal.
distal surface of the distal marginal ridge of the upper first
molar should contact and occlude with the mesial surface • Overbite can be increased, normal, or decreased
of the mesial marginal ridge of the lower second molar (this with an anterior open bite.
is originally from Stoller and was referred to as a Stollerized
• The transverse relationship is usually normal, but a
molar) and secondly, the mesiobuccal cusp of the upper first
crossbite may be present.
permanent molar should occlude in the buccal groove of the
lower first permanent molar. Methods of space provision to treat Class I malocclusion
A Class I malocclusion usually includes a Class I incisor and The authors advocate the use of the acronym (SPEED TRIAL)
molar relationship. Both molar and incisor relationships can to memorise the methods of space provision;
be affected by other dental features and may not be a true • Stripping of the enamel (common).
reflection of the underlying skeletal relationship.
• Proclination of the incisors (common).
Class I malocclusion affects 60% of the Caucasian population
(Todd and Lader, 1991) and 80% of the Arab population (Al • Extraction (common).
Jadidi et al., 2018). • Expansion (common).
Aetiologies of Class I malocclusion • Distalization (mainly in the upper arch and ideally
These include: prescribed before the eruption of the second mo-
lars).
• Evolutionary factors mainly as a trend towards soft
diet leading to lack of attrition and subsequently • Torque, i.e. under torquing (applies for the upper
crowding. incisors only).
• Genetic factors include impacted teeth, congeni- • Rotation correction (applies mainly for the premo-
tally missing teeth and microdontia (spacing). lars and molars).
• Environmental factors, including change in the • Incremental growth (applies when the patient is
muscular balance or equilibrium on the developing growing with an increased overjet). (With the man-
dentition, can lead to crowding and sucking habits dible’s growth, the overjet decreases, which decreas-
may lead to open bite, crossbite, increased vertical es the space requirement for overjet correction.)
dimensions etc. Another factor, trauma, may lead to • Angulation, i.e. under tipping (mainly applied on
crowding due to a change in position of developing upper anterior and lower canine teeth).
tooth buds or tooth impaction and premature loss of
deciduous teeth. • Leeway space (in the late mixed dentition).
Extra-oral features of Class I malocclusion Exam night review
These include: • Angle’s Class I occlusion, Neutrocclusion, MB of
U6 occludes in BG of L6 (rotation, malposition,
• Mostly, mesocephalic head shape. crossbite etc.) (Angle, 1899)
• Skeletally Class I, however, mild Class II or Class III • Andrews’s Class I molar if the distal surface of the
skeletal bases may be seen. distal marginal ridge of U6→ the mesial marginal
• Straight profile. ridge of L7 and the MB cusp of U6→ buccal groove
L6.
• Average vertical proportions.
• Class I incisor relation: Incisor edge of LI occlude
• Soft tissues are usually favourable (except bimaxil-
110 Class 1 Malocclusion

or lie immediately below the cingulum plateau of UI References
(BSI, 1983) AL JADIDI, L., SABRISH, S., SHIVAMURTHY, P. G. & SENGUT-
• Bimax-protrusion usually Class I malocclusion TUVAN, V. 2018. The prevalence of malocclusion and orthodontic
treatment need in Omani adolescent population. J Orthod Sci, 7,
• 60% of the Caucasian population and 80% in Arab 21.
population (Todd and Lader, 1991)(Al Jadidi et al.,
ANGLE, E. H. 1899. Classification of malocclusion. Dental cosmos,
2018) 41, 248-264,350-357.
• Methods of space provision include stripping of BSI 1983. British standard glossary of dental terms, British Stan-
the enamel, proclination of the incisors, extraction, dards Institution.
expansion, distalization, torque changes, rotation
TODD, J. & LADER, D. 1991. Adult dental health, UK 1988. Office
correction, incremental growth, angulation changes
of Population Censuses and Surveys. London: HMSO.
and utilising the Leeway space
• Extra-oral features: Mesencephalic, skeletal Class I
(mild skeletal Class II or III possible), straight pro-
file and average vertical lip fullness
• Intraoral features: Crowding/spacing, Class I inci-
sors, canines and molars, normal overjet and over-
bite, and variable transverse relationship.
• Aetiologies include evolutionary, genetic: and envi-
ronmental factors.
Class 1 Malocclusion 111

Bimaxillary
Proclination
11
Written by: Mohammed Almuzian, Haris Khan, Awrisha Tariq
In this Chapter
1. Aetiologies of bimaxillary proclination
2. Classification of bimaxillary proclination
3. Features of bimaxillary proclination
4. Treatment of bimaxillary proclination
5. Treatment considerations while managing bi
maxillary proclination
6. Relapse after treating bimaxillary dentoalveolar
proclination
7. Exam night review
B imaxillary Proclination is defined as proclination of both
ternal force on the incisors, resulting in bimaxillary
dentoalveolar proclination.
maxillary and mandibular arches or proclination of upper and
lower incisors that cause procumbent lips (Keating, 1986). • Dental factors (McCann and Burden, 1996): The
Controversy exists over the terminology of bimaxillary den- tooth size-arch length discrepancy can be expressed
toalveolar proclination; some researchers believed the term in the form of proclination of incisors. Teeth with
should be used for prognathic maxillary and mandibular jaws a more forward path of eruption cause bimaxillary
only. The term bimaxillary protrusion has been proposed for dentoalveolar proclination.
prognathic jaws and bimaxillary dentoalveolar proclination • Habits: A tongue thrust habit can result in bimaxil-
for proclined upper and lower teeth to differentiate between lary dentoalveolar proclination in both endogenous
jaws and incisors. Bimaxillary dentoalveolar proclination oc- and adaptive forms.
curs when both maxillary and mandibular incisors have been
• Pathological conditions include Cancrum oris, cere-
proclined relative to dental and cranial bases resulting in pro-
bral palsy, hemangioma and untreated cleft lip with
cumbent soft tissue (Burden 1996).
prognathic premaxilla.
Bimaxillary proclination mainly affects Afro-Caribbean’s
Classification of bimaxillary proclination
(Farrow et al., 1993). It is also common among Arab groups
and Asian (Hussein and Mois, 2007), but it is less prevalent in Bimaxillary proclination is classified according to Interincisal
white Caucasian populations (Keating, 1985). angle and include:
Aetiologies of bimaxillary proclination • Mild =125˚-115˚
Bimaxillary dentoalveolar proclination is usually adapted to • Moderate =115˚-105˚
underlying skeletal and soft tissue patterns. The main aetiolo-
• Severe =<105˚
gies are:
However, the cephalometric values should be considered for
• Skeletal factors: It has mostly a genetic origin (Lam-
each race because bimaxillary proclination in one population
berton et al., 1980).
would be considered normal for other people.
• Lip morphology/position (Naini and Gill, 2008):
Features of bimaxillary proclination
In bimaxillary proclination, lips are often full and
everted. Tongue exerts pressure on the teeth so that These include:
dental arches move forward as they grow. The effect
1. Skeletal features (Carter and Slattery, 1988, Keating, 1985)
of soft tissues abnormality at rest is more than dur-
such as:
ing function.
• Prognathic maxillary and mandibular jaws
• Nasal blockage (Solow and Tallgren, 1976b): Due
to nasal blockage, the patient becomes a mouth • Class I Malocclusion
breather, leading to bimaxillary dentoalveolar pro- • Mild class II malocclusion
clination.
• Short posterior cranial base
• Soft tissue stretching theory (Solow and Kreiborg,
1977, Solow and Tallgren, 1976b): This theory pro- • Small posterior Facial height
poses that airway obstruction leads to a neuromus- • Divergent facial planes with steep mandibular plane
cular feedback mechanism, where patients can’t angle
breathe through the nose due to nasal obstructions
or enlarged adenoids, so they adopt a ‘head-up pos- • Increased FMPA
ture’ with the extension of the neck. This leads to 2. Dental features such as:
stretching of suprahyoid muscles, skin and fascia.
This, in turn, imparts a force on the mandible leading • There is dental proclination in both upper and lower
to a downward posture. The tongue, therefore, occu- arches (Carter and Slattery, 1988). The lower incisor
pies a lower position. There is less internal soft tissue proclination compensates for the ANB difference.
force on the maxillary arch (in the transverse plane). Due to the proclination of the incisor, the overbite
The external force of the cheeks results in a narrower is mostly decreased, and, in some cases, the anterior
maxillary arch, potentially causing a crossbite. At open bite may be present.
the same time, the tongue is positioned forwards to • Both dental arches are larger in length due to the
increase the pharyngeal space to aid breathing. The proclination of teeth resulting in spacing and dia-
forward position of the tongue imparts a greater in- stema.
114 Bimaxillary Proclination

• The overjet may be normal or increased. ship is class II with no lower crowding. IPR in the
lower arch combined with upper extractions or IPR
• Molar relations are usually class I.
in both arches can be performed to provide space. If
• The size of teeth is usually large as compared to av- enmasse retraction is desired, TADs provide better
erage population (McCann and Burden, 1996). As anchorage than conventional anchorage. TADs can
bimaxillary proclination is more common in Afro- also decrease vertical proportions due to an intru-
Caribbeans’ study, (Keene, 1979) reported that sive effect depending on the direction and level of
tooth size for the overall maxillary and mandibular force application (Upadhyay et al., 2008).
dentition among black people was on average 8.4%
• Severe cases: Orthognathic surgery is proposed to
larger than for whites.
correct significant skeletal problems using a subapi-
3. Soft tissue features (In Africa-Caribbean)(Connor and cal osteotomy with or without genioplasty. In cases
Moshiri, 1985): typically, patients present with: of AOB, surgical maxillary posterior impaction and
clockwise rotation of the occlusal plane is the treat-
• Convex facial form
ment of choice (Chu et al., 2009). Anterior segmen-
• Increased lip length tal osteotomy can be used if the overjet is increased.
• Everted lips In black females, lips are more protrud- This type of surgery can also be helpful if the patient
ed than in white females (Fonseca and Klein, 1978). has a gummy smile and underdeveloped chin posi-
tion (Lee et al., 2007).
• Incompetent lips
Relapse after treating bimaxillary dentoalveolar proclina-
• Long and thick tongue (Adesina et al., 2013) tion
• Low lower lip line, high upper lip line (Keating, Teeth remain in an equilibrium between external forces ex-
1985) erted by lips and cheek and internal forces of the tongue. If
• Receded chin the equilibrium is changed due to tooth movement, there are
greater chances of relapse, as the forces seek to move the teeth
• Holdaway angle increased with prominent lips back to the equilibrium position. In bimaxillary dentoalveo-
• Acute nasolabial angle and labiomental angle lar proclination cases, stability depends upon lip and tongue
adaptation to incisor retraction. Ideally, the interincisal angle
Treatment of bimaxillary proclination is normalised with good buccal interdigitation. 20% of the
The main treatment objectives are (Carter and Slattery, 1988): treated bimaxillary dentoalveolar proclination Class I cases
had a relapse of the inter-incisal angle, while Class II cases
• Improve aesthetics, i.e. flatten profile. showed a 30% relapse (Keating, 1986). VFR supporting per-
• Improve lip competency. manent fixed retainers are advised. Upper incisors should be
covered by one-third of the lower lip.
• Alignment and levelling.
• Correction of incisor relationship. Exam night review
• Maintenance of a stable result. • Proclination of maxillary & mandibular arches or
Treatment considerations while managing bimaxillary a condition in which upper and lower incisors are
proclination proclined →procumbent lips
These include: •
Most common Afro-Caribbean’s (Farrow et al.,
1993)
•
Mild bimaxillary dentoalveolar proclination: In
growing patients, no treatment is required as protru- • Less prevalent in white Caucasian (Keating, 1985).
sion can be masked by the forward and downward Aetiology
movement of the nose and the ageing effect. In a
mild case, interproximal reduction (IPR) can also be • Skeletal factors.
performed to provide space for incisor retraction. • Lip morphology/position (Naini and Gill, 2008).
• Moderate bimaxillary dentoalveolar proclination: • Nasal blockage (Solow and Tallgren, 1976a).
First, premolar extractions are the treatment of
choice if the molar relation is Class I to reduce soft • Soft tissues stretching theory (Solow and Kreiborg,
tissue procumbence (Bills et al., 2005). Upper arch 1977, Solow and Tallgren, 1976b).
extractions may be indicated if the molar relation- • Enlarged adenoids.
Bimaxillary Proclination 115

• Endogenous (primary) thrust. • AOB, max post intrusion/surgical impaction →rota-
tion of occlusal plane is treatment of choice (Chu et
• Dental factors.
al., 2009)
• Habits.
• Anterior segmental osteotomy for overjet, gummy
• Pathological conditions. smile & underdeveloped chin (Lee et al., 2007)
Classification Relapse
• Mild =125˚-115˚. • Stability depends upon lip adaptation to incisor re-
traction.
• Moderate =115˚-105˚.
• IIA is normalized with good buccal interdigitation.
• Severe = <105˚.
• VFR supporting permanent fixed retainer.
Skeletal features
• Long term stability is unpredictable.
• Prognathic maxillary and mandibular jaws.
• UI covered 1/3rd lower lips.
• Divergent facial planes with steep mandibular plane
angle.
Dental features
• Dental bimaxillary dentoalveolar proclination,
IIA.
• Proclined LLS.
• overbite & openbite tendency.
• Larger dental arches with spacing.
• Normal overjet.
• Molar relations usually Class I.
Soft tissue features
• Convex facial form.
• Lip incompetency.
• Acute LNA and LMA.
• Everted lips in black females.
Management
Mild bimaxillary dentoalveolar proclination cases
• In growing patients --no treatment.
• In mild cases (IPR).
Moderate bimaxillary dentoalveolar proclination cases
• First premolar extraction → treatment of choice
• If molar relation Class II treat with extraction of up-
per molars.
• Avoid Class II elastics → extrusive effect (Koyama
et al., 2010)
Severe cases
• Orthognathic surgery for severe skeletal problems.
116 Bimaxillary Proclination

References: European Journal of Orthodontics, 18, 617-621.
ADESINA, B. A., OTUYEMI, O. D., KOLAWOLE, K. A. & AD- NAINI, F. B. & GILL, D. S. 2008. Facial aesthetics: 2. Clinical as-
EYEMI, A. T. 2013. Assessment of the impact of tongue size in sessment. Dental update, 35, 159-170.
patients with bimaxillary protrusion. International orthodontics,
SOLOW, B. & KREIBORG, S. 1977. Soft-tissue stretching: a pos-
11, 221-232.
sible control factor in craniofacial morphogenesis. Scand J Dent
CARTER, N. & SLATTERY, D. 1988. Bimaxillary proclination in Res, 85, 505-7.
patients of Afro-Caribbean origin. British journal of orthodontics,
SOLOW, B. & TALLGREN, A. 1976a. Head posture and craniofa-
15, 175-184.
cial morphology. American Journal of Physical Anthropology, 44,
CHU, Y.-M., BERGERON, L. & CHEN, Y.-R. Bimaxillary protru- 417-435.
sion: an overview of the surgical-orthodontic treatment. Seminars
SOLOW, B. & TALLGREN, A. 1976b. Head posture and craniofa-
in plastic surgery, 2009. © Thieme Medical Publishers, 032-039.
cial morphology. Am J Phys Anthropol, 44, 417-35.
CONNOR, A. M. & MOSHIRI, F. 1985. Orthognathic surgery
UPADHYAY, M., YADAV, S., NAGARAJ, K. & PATIL, S. 2008.
norms for American black patients. American journal of orthodon-
Treatment effects of mini-implants for en-masse retraction of an-
tics, 87, 119-134.
terior teeth in bialveolar dental protrusion patients: a randomized
FARROW, A. L., ZARRINNIA, K. & AZIZI, K. 1993. Bimaxillary controlled trial. American Journal of Orthodontics and Dentofacial
protrusion in black Americans—an esthetic evaluation and the Orthopedics, 134, 18-29. e1.
treatment considerations. American journal of orthodontics and
dentofacial orthopedics, 104, 240-250.
FONSECA, R. J. & KLEIN, W. D. 1978. A cephalometric evaluation
of American Negro women. American journal of orthodontics, 73,
152-160.
GERMEÇ, D. & TANER, T. U. 2008. Effects of extraction and
nonextraction therapy with air-rotor stripping on facial esthetics in
postadolescent borderline patients. American Journal of Ortho-
dontics and Dentofacial Orthopedics, 133, 539-549.
HUSSEIN, E. & MOIS, M. A. 2007. Bimaxillary protrusion in the
Palestinian population. The Angle orthodontist, 77, 817-820.
JACOBS, J. D. & BELL, W. H. 1983. Combined surgical and orth-
odontic treatment of bimaxillary protrusion. American journal of
orthodontics, 83, 321-333.
KEATING, P. 1985. Bimaxillary protrusion in the Caucasian: a
cephalometric study of the morphological features. British journal
of orthodontics, 12, 193-201.
KEATING, P. 1986. The treatment of bimaxillary protrusion: a
cephalometric consideration of changes in the inter-incisal angle
and soft tissue profile. British journal of orthodontics, 13, 209-220.
KEENE, H. J. 1979. Mesiodistal crown diameters of permanent
teeth in male American Negroes. Am J Orthod, 76, 95-9.
KOYAMA, I., IINO, S., ABE, Y., TAKANO-YAMAMOTO, T. &
MIYAWAKI, S. 2010. Differences between sliding mechanics with
implant anchorage and straight-pull headgear and intermaxillary
elastics in adults with bimaxillary protrusion. The European Jour-
nal of Orthodontics, 33, 126-131.
LAMBERTON, C. M., REICHART, P. A. & TRIRATANANIMIT, P.
1980. Bimaxillary protrusion as a pathologic problem in the Thai.
American journal of orthodontics, 77, 320-329.
LEE, J. K., CHUNG, K. R. & BAEK, S. H. 2007. Treatment out-
comes of orthodontic treatment, corticotomy-assisted orthodontic
treatment, and anterior segmental osteotomy for bimaxillary den-
toalveolar protrusion. Plast Reconstr Surg, 120, 1027-36.
MCCANN, J. & BURDEN, D. J. 1996. An investigation of tooth size
in Northern lrish people with bimaxillary dental protrusion. The
Bimaxillary Proclination 117

Class II Division 1
Malocclusion
12
Written by: Mohammed Almuzian, Haris Khan, Zahid Majeed
In this Chapter
1. Incidence of Class II Division 1 malocclusion 12. Favourable features for orthodontics camouflage
2. Aetiology of Class II Division 1 malocclusion 13. Combined orthodontic-surgical approach
3. Features of Class II Division 1 malocclusion 14. Indicators for orthognathic surgery
4. Type of lip behaviour 15. Aetiology of relapse
5. Justifications for early treatment of Class II mal 16. Enhancing the stability of treated Class II Divi
occlusions sion 1 malocclusions
6. Treatment timing for Class II Division 1 maloc 17. EXAM NIGHT REVIEW
clusion
7. Class II growth modification / functional jaw
orthopaedics
8. Effects of Class II functional appliances
9. The proposed advantages of the phase I inter
vention
10. Effectiveness of phase I intervention
11. Orthodontics camouflage to treat Class II Divis
ion 1 malocclusion
C lass II incisor relationship describes a situation where the
•
•
Digit sucking.
Mouth breathing.
incisal edges of the mandibular incisors lie posterior to the
cingulum plateau of the maxillary incisors, the upper inci- • Tongue thrusting
sors are either proclined or have a normal inclination, and the
Features of Class II Division 1 malocclusion
overjet is increased (BSI, 1983).
These include:
Class II molars relationship describes a situation where the
mesiobuccal cusp of the permanent maxillary first molar lies 1. Skeletal Features (Hopkins et al., 1968): A Class II malocclusion
mesial to the buccal groove of the permanent first mandibu- is common on a skeletal Class II base (76% of the cases have skeletal
lar molar. Class II intermediate is defined as a Class II incisor class 2 bases). However, they can be found on a skeletal Class I base
and rarely on a skeletal Class III base. A skeletal Class II relationship
relationship with an increased overjet (5-7mm) with upright
is mainly due to mandibular retrognathia (75%) and less commonly
upper incisors. In contrast, Class II indefinite is defined as due to a prognathic maxilla (25%). Retro-positioning of the man-
one upper central incisor proclined and one retroclined. The dible can be due to an increase in the cranial base angle. However,
cephalometric definition of Class II is when the ANB angle is an increase in the cranial base length leads to a prognathic maxilla.
greater than 4° for the Caucasian population. If a Class II malocclusion exists on a skeletal Class I base, the incisor
relationship may be due to the soft tissue or environmental factors,
for example, digit sucking or a lower lip trap.
Incidence of Class II Division 1 malocclusion 2. Dental Features such as:
The incidence of Class II Division 1 is 20% (Todd and Lader, 1991),
• Increased overjet.
representing the most prevalent malocclusion in Caucasian popu-
lations (Foster and Walpole Day, 1974, Helm, 1968, Proffit et al., • Spacing of the upper incisors.
1998). The prevalence of Class II intermediate is 10% (Williams
and Stephens, 1992), while Class II indefinite is found in 9 % of the • Lower incisors are crowded or proclined depending
population. (which population) upon the lower lip trap.
Aetiology of Class II Division 1 malocclusion • Deep bite, or an open bite.
These include: • An open bite may exist due to an adaptive swallow-
1. Skeletal factors such as: ing pattern, secondary to increased overjet,
• The effect of teratogens on mandibular growth. • A Class II subdivision malocclusion exhibits an

asymmetry in the buccal segments; one side is Class
• Fetal moulding, suppressing the growth of the man- II, and the other is Class I.
dible
• Posterior crossbites may be present due to antero-
• Trauma to the TMJ during the birthing process; posterior discrepancy in jaw position secondary to
childhood fractures of the jaw; or arthritic problems. habits.
2. Dental factors such as: • Deep curve of Spee due to supra-eruption of inci-
• Macrodontia of the upper teeth or microdontia of sors.
the lower teeth 3. Cephalometric features such as:
• Crowding in the upper arch. • Increased cranial base angle.
• Supernumerary teeth in the upper arch or hypodon- • Increased ANB angle.
tia in the lower arch.
• Morphologically, short or retrognathic mandible.
• Pathological forward migration of teeth.
• Prognathic maxilla.
3. Soft tissue factors such as:
•
Variable maxillary-mandibular plane angle (in-
• Lip incompetence, short upper lip leading to flared creased or reduced).
upper incisors.
• Variable gonial angle (increased or reduced).
• Lower lip trap.
• Variable lower facial height (increased or reduced).
• Hypotonic upper lip.
• Decreased inter-incisal angle.
• Lower lip to palate swallowing
4. Soft tissue features such as:
4. Habits such as:
• Convex profile and soft tissues may be retrusive to
120 Class II Division 1 Malocclusion

Rickett’s E line. Permanent dentition: Treatment options in permanent dentition
are:
• Reduced nasolabial angle.
• Growth modification,
• Incompetent, potentially competent lips.
• Orthodontic camouflage.
• Lower lip trapping.
• Combined orthodontics and surgical approach.
• Hypotonic upper lip.
Growth modification / functional jaw orthopaedics to treat
• The lower lip is not covering the upper incisors. Class II Division 1 malocclusion
• Retruded chin. Growth modification appliances are used to alter/ remove the re-
Type of lip behaviour to achieve anterior oral seal in pa- strictive effects of masticatory and facial muscles, therefore, chang-
ing the skeletal, soft tissue and dental relationships. Growth modi-
tients with Class II malocclusion
fication appliances maximise the patient’s potential growth. Growth
These include: modification is usually used as phase 1 intervention (early treat-
ment) during the mixed dentition or as phase 2 definitive treat-
• Lower lip to the palate: The lower lip rests palatal ment (delayed treatment) with/without fixed appliances during
to the maxillary incisors. This is associated with ret- the permanent dentition (Taffarel et al., 2018). The post-functional
roclined lower incisors and/or proclined upper inci- fixed appliance phase aims to improve finishing and detailing of the
sors. occlusion, retain the corrected overjet, tip/torque of incisors, and
achieve Class I with the condyle centred in the fossa.
• Lower lip to tongue: The tongue is pushed forward
to contact the lower lip, resulting in an incomplete Effects of Class II functional appliances
deep bite. The mandibular incisors are often pro- These include:
clined. This forward posture of the tongue can be
described as an adaptive tongue thrust. • They enhance mandibular growth with increased
condylar height and length and remodelling in the
• Forward posturing of the mandible: It allows the glenoid fossae. However, these changes cannot be
lips to meet together. In this scenario, the soft tissues more than what is genetically predetermined.
promote dentoalveolar compensation, decreasing
the effect of the skeletal Class II pattern. This habit- • Restriction of maxillary skeletal growth (headgear
ual forward posturing of the mandible is also known effect).
as a ‘Sunday bite’. • Increased pterygoid muscle activity followed by
Justifications for early treatment of Class II malocclusions adaptive condylar growth during treatment (1-
3mm).
These include:
• Distal tipping of upper posterior teeth.
• Trauma (Todd and Dodd, 1985): The risk of trauma
when the overjet is greater than 9mm in 12yr old is • Retroclination of the upper anterior teeth.
around 45% (Batista et al., 2018), early intervention • Mesialization of the lower posterior teeth.
results in a small decrease in this risk.
• Proclination of the lower incisors.
• Self-esteem (O’Brien et al., 2003b): Early overjet re-
duction may help to improve a patient’s self-concept • Differential upward and forward eruption of the
scores. lower buccal segments results in a clockwise rotation
of the occlusal plane and increased facial height.
• Bullying (Seehra et al., 2011): 12.8% of patients re-
ferred for treatment are bullied, particularly those • Expansion of the maxillary buccal segments if an ex-
with an increased overjet. pansion screw is incorporated.
• To eliminate a traumatic bite by the lower incisors. The proposed advantages of the phase I intervention
Treatment timing for Class II Division 1 malocclusion These include:
Treatment can be performed during: •

Reduction in the incidence of incisor trauma
(O’Brien et al., 2003a).
Primary dentition: Treatment during primary dentition is no longer
indicated. • Improvements in self-esteem and increase in self-
Mixed dentition: Growth modification can start 1-3 years before the concept (O’Brien et al., 2003a).
peak adolescent growth spurt. However, transitioning to permanent • Improves skeletal pattern.
dentition can be clinically challenging to manage.
Class II Division 1 Malocclusion 121

• Reduces the length of subsequent phase 2 treatment • Space can also be provided through extraction. In
(usually fixed appliances). the long-term, the post-treatment stability regard-
ing overjet, overbite, canine and molar relationships
• Reduces the need for extractions in phase 2 treat-
have similar results in extraction and non-extraction
ment.
Class II malocclusion cases (Janson et al., 2012).
• Relief of gingival trauma. Similarly, correction of Class II malocclusions either
with the extraction of 2 maxillary units or extrac-
• Changes are more likely in early treatment as cra-
tion of 4 units (2 lower extractions as well ) results
niofacial tissues are more malleable at a younger age.
in a similar long-term stability (Janson et al., 2009).
Disadvantages of phase I intervention However, proper inter-cuspal interdigitation after
These include: debonding is essential in enhancing the achieved
occlusion (Chhibber et al., 2010).
• Patient compliance might be burnt due to the in-
creased duration of the overall treatment. Favourable features for orthodontics camouflage
• Soft tissues do not mature until 15 years of age. These include:

Therefore, the lag in vertical lip growth may com- 1. Intervention during active growth is considered favour-
promise the stability of the corrected overjet. able due to potential mandibular growth (mandibular growth
Effectiveness of phase I intervention (Thiruvenkatachari follows a similar pattern to somatic growth).
et al., 2015, Batista et al., 2018) 2. Favourable skeletal features such as:
According to a Cochrane review (Batista et al., 2018), 2 stage treat- • Class I or mild Class II skeletal base relationship.
ment (i.e. early treatment followed by fixed appliances in the per-
manent dentition) is not particularly advantageous over 1 stage of • Average or reduced lower face height.
treatment in adolescence (i.e. functional appliance treatment fol-
lowed by fixed appliances consecutively), except for a reduction in • Mild transverse discrepancies.
the incidence of incisal trauma. Trauma is the strongest indication 3. Favourable dental features (Burden et al., 1999) such as:
for early treatment, though the risk, benefit, efficacy and cost could
not be established (King et al., 1990). • Overjet of less than 9mm, favourably if combined
with proclined upper incisors.
Another study suggests that incisor injuries tend to be minor, so
incisor trauma treatment is minimal compared with the cost of 2 • Average or slightly increased overbite.
phase orthodontic treatment (Koroluk et al., 2003).
• Mild to moderate crowding.
Orthodontics camouflage to treat Class II Division 1 mal-
occlusion • The molar relationship is less than 3/4 unit Class II.
Objectives of orthodontic camouflage of Class II Division 1 maloc- Combined orthodontic-surgical approach

clusion are: The routine surgical procedure for treating a moderate to se-
• Relief of crowding. vere Class II dentoskeletal deformity is a bilateral sagittal split
ramus osteotomy (BSSO) to advance the mandible. Alterna-
• Level and align the arches. tively, a vertical sub-sigmoid osteotomy or total mandibular
• Normalise the overjet and overbite. subapical alveolar osteotomy can be prescribed in some cases
(Pangrazio-Kulbersh et al., 2001).
• Correction of buccal segment relationship.
Indicators for orthognathic surgery
• Midline correction.
These include:
• Lower lip resting over upper incisors.
• Adult/non-growing patients.
Orthodontics camouflage treatment modalities to treat
Class II Division 1 malocclusion • If orthodontic treatment alone can cause detrimen-
tal effects on the facial aesthetics and oral tissues.
These include:
However, borderline cases have shown to be pleas-
• An upper removable appliance (URA) can be used ing in both surgical and non-surgical cases (Mihalik
when simple tipping of upper incisors is required. et al., 2003)).
• Distalization of the upper arch might be prescribed • Severe skeletal discrepancy cannot be corrected by
to provide space for overjet correction and relieve orthodontics alone. Theoretically, this can be deter-
crowding. mined using different yardsticks. For example, Prof-

fit (Proffit et al., 1992) suggested that surgical inter- Exam night review
vention is indicated if the overjet of 10mm or more,
• Incisal edges of LI posterior to the cingulum plateau
the Pog to Nasion perpendicular is 18mm or more,
of UI while UIs are either proclined or normal incli-
the mandibular corpus length is less than 70 mm and
nation. Overjet is increased (BSI 1983).
facial height more than 125mm. Squire (Squire et al.,
2006) stated that surgical intervention is advisable • Class II intermediate similar Class II/1 with overjet
if the transverse discrepancy is greater than 3mm, (5-7mm) but UI upright/slightly retroclined.
which is not considered amenable to orthodontic
• Class II/1 with one upper central incisor proclined
treatment alone and ANB greater than 9° combined
& one retroclined called Class 2II indefinite.
with severe vertical or transverse discrepancy with
decreased incisor show on a smile. Incidence
Aetiology of relapse of the treated Class II Division 1 mal- • 20% (Todd and Lader, 1991) most prevalent mal-
occlusion occlusion in Caucasians (Foster and Walpole Day,
1974, Helm, 1968, Proffit et al., 1998).
These include:
• Class II intermediate 10% (Williams and Stephens,
• Biological factors: Lack of gingival and periodontal
1992), class 2 indefinite 9 %.
remodelling.
Aetiology
• Iatrogenic factors: Movement of teeth out of soft tis-
sue equilibrium. • Skeletal factors.
• Growth factors: Differential growth factors that pre- • Dental factors.
dispose to relapse.
• Soft tissue influences.
• Environmental factors: continued parafunctional
• Habits.
habits.
Justifications for the early treatment class 2 malocclusion
• Idiopathic causes: Idiopathic condylar resorption
(ICR). • Reduce the risk of trauma: Risk of trauma when
overjet greater than 9mm in 12yr old is around 45%
• Lack of lower lip coverage on upper incisors
(Batista et al., 2018).
• Any combination of the above.
• Improve self-esteem (O’Brien et al., 2003b).
Enhancing the stability of treated Class II Division 1 mal-
• Reduce the risk of bullying (Seehra et al., 2011).
occlusions
• Eliminate traumatic bite by lower incisors.
These include:
The claimed reasons/advantages for early treatment in mixed
• Overcorrection.
dentition phase (O’Brien et al., 2003a)
• Long term permanent retainers.
• Reduction in the incidence of incisor trauma,
•
Continuation of headgear/functional appliances
• Improvements in self-esteem and increase in self-
part-time, for example, at night until growth has
concept,
ceased.
• Improves skeletal pattern,
• Discontinuation of habits.
• Reduces the length of subsequent phase 2 treatment.
• Occlusal interdigitation is an essential factor in the
stability of the achieved corrections. • Reduces the need for extractions in phase 2 treat-
ment.
• If lower incisors are being moved by more than
2mm, they should be retained permanently. • Relief of gingival trauma.
• In case of upper incisor retraction, they should be • Treatment is easy in that stage as craniofacial tissues
retracted within the control of the lower lip. are more malleable.
• Correct lower incisor edge centroid relationship. Favourable features for orthodontics camouflage
• Minimise posterior teeth extrusion in adult patients. 1. Growth features: Mandibular growth follows a
somatic growth pattern. Growth ceased in adults.

2. Skeletal features: References
• Class I or mild Class II skeletal base relationship. BATISTA, K. B., THIRUVENKATACHARI, B., HARRISON, J. E. &
D O’BRIEN, K. 2018. Orthodontic treatment for prominent upper
• Average or reduced lower face height. front teeth (Class II malocclusion) in children and adolescents.
Cochrane Database of Systematic Reviews.
• Very mild transverse discrepancies.
BSI 1983. British standard glossary of dental terms, British Stan-
Dental features (Burden et al., 1999): dards Institution.
• Favourable if overjet is less than 9mm and com- BURDEN, D. J., MCGUINNESS, N., STEVENSON, M. & MC-
bined with proclined incisors. NAMARA, T. 1999. Predictors of outcome among patients with
Class II Division 1 malocclusion treated with fixed appliances in
• Average or slight increased overbite.
the permanent dentition. American journal of orthodontics and
• Mild to moderate crowding. dentofacial orthopedics, 116, 452-459.
• Molar relationship is less than 3/4 unit Class II. CHHIBBER, A., UPADHYAY, M., URIBE, F. & NANDA, R. 2010.
Long-term stability of Class II correction with the Twin Force Bite
Indicators for orthognathic surgery Corrector. Journal of clinical orthodontics: JCO, 44, 363-376.
• Adult/non-growing patients. FOSTER, T. & WALPOLE DAY, A. 1974. A survey of malocclu-
sion and the need for orthodontic treatment in a Shropshire school
• Severe skeletal discrepancy. population. British Journal of Orthodontics, 1, 73-78.
• Overjet 10mm or more. HELM, S. 1968. Malocclusion in Danish children with adolescent
• Pog to Nasion perpendicular is 18mm or more. dentition: an epidemiologic study. American journal of orthodon-
tics, 54, 352-366.
• Mandibular corpus length is less than 70 mm.
HOPKINS, G., HOUSTON, W. & JAMES, G. 1968. The cranial base
• Facial height more than 125mm. as an aetiological factor in malocclusion. Angle Orthod, 38, 250-5.
• Transverse discrepancies greater than 3mm were JANSON, G., ARAKI, J. & CAMARDELLA, L. T. 2012. Posttreat-
not considered orthodontically treatable. ment stability in Class II nonextraction and maxillary premolar
extraction protocols. ORTHODONTICS: The Art & Practice of
• ANB is greater than 9°. Dentofacial Enhancement, 13.
• Severe vertical or transverse discrepancy. JANSON, G., LEON-SALAZAR, V., LEON-SALAZAR, R., JAN-
SON, M. & DE FREITAS, M. R. 2009. Long-term stability of Class
• Severe deep bite with decreased incisor show on a II malocclusion treated with 2-and 4-premolar extraction proto-
smile. cols. American Journal of Orthodontics and Dentofacial Orthope-
Aetiologies of relapse of treated Class II Division 1 malocclu- dics, 136, 154. e1-154. e10.
sion KING, G. J., KEELING, S. D., HOCEVAR, R. A. & WHEELER,
T. T. 1990. The timing of treatment for Class II malocclusions in
• Biological factors: Lack of gingival and periodontal children: a literature review. Angle Orthod, 60, 87-97.
remodelling,
KOROLUK, L. D., TULLOCH, J. F. & PHILLIPS, C. 2003. Incisor
• Iatrogenic factors: Movement of teeth out of equilib- trauma and early treatment for Class II Division 1 malocclusion.
rium of soft tissue Am J Orthod Dentofacial Orthop, 123, 117-25; discussion 125-6.
• Growth factors: Differential growth factor which MIHALIK, C. A., PROFFIT, W. R. & PHILLIPS, C. 2003. Long-
predisposes to relapse. term follow-up of Class II adults treated with orthodontic
camouflage: a comparison with orthognathic surgery outcomes.
• Environmental factors: continued parafunctional American Journal of Orthodontics and Dentofacial Orthopedics,
habits, 123, 266-278.
• Idiopathic causes: Idiopathic condylar resorption O’BRIEN, K., WRIGHT, J., CONBOY, F., CHADWICK, S.,
(ICR), OR CONNOLLY, I., COOK, P., BIRNIE, D., HAMMOND, M.,
HARRADINE, N., LEWIS, D., MCDADE, C., MITCHELL, L.,
• Any combination of the above. MURRAY, A., O’NEILL, J., READ, M., ROBINSON, S., ROBERTS-
HARRY, D., SANDLER, J., SHAW, I. & BERK, N. W. 2003a.
Effectiveness of early orthodontic treatment with the Twin-block
appliance: a multicenter, randomized, controlled trial. Part 2: Psy-
chosocial effects. Am J Orthod Dentofacial Orthop, 124, 488-94;
discussion 494-5.
O’BRIEN, K., WRIGHT, J., CONBOY, F., SANJIE, Y., MANDALL,

N., CHADWICK, S., CONNOLLY, I., COOK, P., BIRNIE, D.,
HAMMOND, M., HARRADINE, N., LEWIS, D., MCDADE, C.,
MITCHELL, L., MURRAY, A., O’NEILL, J., READ, M., ROBIN-
SON, S., ROBERTS-HARRY, D., SANDLER, J. & SHAW, I. 2003b.
Effectiveness of early orthodontic treatment with the Twin-block
appliance: a multicenter, randomized, controlled trial. Part 1:
Dental and skeletal effects. Am J Orthod Dentofacial Orthop, 124,
234-43; quiz 339.
PANGRAZIO-KULBERSH, V., BERGER, J. L., KACZYNSKI, R. &
SHUNOCK, M. 2001. Stability of skeletal Class II correction with 2
surgical techniques: the sagittal split ramus osteotomy and the total
mandibular subapical alveolar osteotomy. American Journal of
PROFFIT, W., FIELDS, J. H. & MORAY, L. 1998. Prevalence of
malocclusion and orthodontic treatment need in the United States:
estimates from the NHANES III survey. The International journal
of adult orthodontics and orthognathic surgery, 13, 97-106.
PROFFIT, W. R., PHILLIPS, C., TULLOCH, J. F. & MEDLAND,
P. H. 1992. Surgical versus orthodontic correction of skeletal Class
II malocclusion in adolescents: effects and indications. Int J Adult
Orthodon Orthognath Surg, 7, 209-20.
SEEHRA, J., FLEMING, P. S., NEWTON, T. & DIBIASE, A. T.
2011. Bullying in orthodontic patients and its relationship to mal-
occlusion, self-esteem and oral health-related quality of life. Journal
SQUIRE, D., BEST, A. M., LINDAUER, S. J. & LASKIN, D. M.
2006. Determining the limits of orthodontic treatment of overbite,
overjet, and transverse discrepancy: a pilot study. Am J Orthod
TAFFAREL, I. P., SAGA, A. Y., LOCKS, L. L., RIBEIRO, G. L. &
TANAKA, O. M. 2018. Clinical Outcome of an Impacted Maxillary
Canine: From Exposition to Occlusion. J Contemp Dent Pract, 19,
1552-1557.
THIRUVENKATACHARI, B., HARRISON, J., WORTHINGTON,
H. & O’BRIEN, K. 2015. Early orthodontic treatment for Class II
malocclusion reduces the chance of incisal trauma: Results of a
Cochrane systematic review. Am J Orthod Dentofacial Orthop,
148, 47-59.
TODD, J. E. & DODD, T. 1985. Children’s Dental Health in the
United Kingdom, 1983: A Survey Carried Out by the Social Survey
Division of OPCS, on Behalf of the United Kingdom Health
Departments, in Collaboration with the Dental Schools of the Uni-
versities of Birmingham and Newcastl, Stationery Office.
TODD, J. E. & LADER, D. 1991. Adult dental health 1988 United
Kingdom, HM Stationery Office.
WILLIAMS, A. C. & STEPHENS, C. D. 1992. A modification to the
incisor classification of malocclusion. Br J Orthod, 19, 127-30.

Class II Division 2
malocclusion
13
In this Chapter
1. Classification of Class II Division 2 malocclusion
2. Incidence of Class II Division 2 malocclusion
3. Aetiology of Class II Division 2 malocclusion
4. Features of Class II Division 2 incisor relation
ships
5. Justification for treatment
6. Treatment aims
7. Treatment considerations
8. Treatment option
9. Timing of treatment
10. Stability and retention
11. Proclination of lower incisors in Class II Divi
sion 2 cases
C lass II Incisor relationship: The lower incisor edge oc-
nines among Class II Division 2 subjects (Basdra et
al., 2000).
cludes palatal to the cingulum plateau of the upper central
incisor, with retroclined upper incisors and the overjet usu- 2. Environmental factors such as:
ally being minimal or possibly increased (BSI, 1983). If the • Soft tissue factors: A high resting position of the
overjet is in the range of 5-7 mm and incisors are retroclined, lower lip over the upper incisors results in increased
it is known as Class II intermediate (Williams, 1992) resting pressure, approximately 2.5 times greater
Classification of Class II Division 2 malocclusion than upper lip resting pressure, which is linked with
retroclination of the maxillary incisors (Lapatki et
Van der Linden’s sub-classification of Class II Division 2 is al., 2002). Hyperactive or hypertonic lips or a ‘strap-
based on the position of the upper incisors and canines rela- like lower lip’ have been implicated in the Class II
tive to each other (Van der Linden, 1983). Division 2 (Karlsen, 1994).
• Type A: The upper central and lateral incisors are • Dental factors such as overeruption of the incisors,
retroclined, with no overlapping by canines. It is less long central and short lateral incisors, which results
severe in nature. in the lateral incisors ‘escaping’ from the effects of
• Type B: The central incisors are retroclined and the lower lip force, increased crown root angle of the
overlapped by the lateral incisors. upper incisor, known as the Collum angle (McIntyre
and Millett, 2003), and thin incisors with small cin-
• Type C: The central and lateral incisors are retro- gulum.
clined and overlapped by the canines.
• Skeletal factors due to increased cranial base length
• Type D: A combination of the above subtypes. and angle (Hopkins et al., 1968) or reduced lower
Incidence of Class II Division 2 malocclusion facial height (Pancherz et al., 1997).
Class II Division 2 is a relatively uncommon malocclusion, • Growth factors due to overdevelopment of the up-
representing 2.3-5% of all malocclusions of the Western Cau- per anterior alveolar process or forward rotation of
casian population (Ast et al., 1965)(Mills, 1966). The preva- the mandible result in the lower lip moving superi-
lence in children in the United Kingdom is 10% (Millett et al., orly in position.
2012, Foster and Day, 1974). Features of Class II Division 2 incisor relationships
Aetiology of Class II Division 2 malocclusion 1. Skeletal features such as
Class II Division 2 is a combination of environmental and • Usually mild Class II skeletal base but can be I or III.
genetic factors.
• Increased cranial base angle leading to mandibular
1. Genetic and familial origin: The evidence that Class II retrognathia (Hopkin et al., 1968).
Division 2 could have a genetic component are:
• Longer cranial base leading to the prognathic max-
• The study of 20 monozygotic twins showed that illa.
all twins had a Class II Division 2 incisor relation-
ship, while only 10.7% of 28 dizygotic twins had a • Decreased lower face height, gonial angle, mandib-
Class II Division 2 incisor relationship (Markovic, ular plane angle and skeletal deep bite (Al-Khateeb
1992). The high concordance in monozygotic twins and Al-Khateeb, 2009).
and much lower concordance for dizygotic twins • Maxilla may be short, broad and forward relative to
suggests that Class II Division 2 have an autosomal the mandible leading to a tendency for a scissor bite.
dominant inheritance pattern, with more than one
genetic factor contributing to this malocclusion. 2. Soft tissue features such as
• Tooth agenesis, excluding third molars, was at least • High resting lower lip line due to decreased lower
three times more common in Class II Division 2 face height.
subjects than in the general population (Basdra et • Typically strap-like lower lip (increase in muscular
al., 2000). tone).
• Reduced width of lateral incisors had a greater prev- • Marked labio-mental fold, and
alence in Class II Division 2 incisor relationships
• High masseteric muscle forces due to hypertrophic
(Peck et al., 1998).
muscle (Ingervall and Thilander, 1974,Sciote et al.,
• An increased prevalence of impacted maxillary ca- 2012).

3. Dental features such as: These include:
• Increased inter-incisal angle, • Crown-root angle (Collum angle): A large angle has
been suggested as the possible reason for the deep
• Pronounced retroclination of the upper central inci-
overbites generally observed in Class II Division 2
sors (Brezniak et al., 2002).
incisor cases. Increased crown-root angle can in-
• Retroclined upper and lower incisors. crease an individual’s risk for root resorption when
intruding, extruding and torquing teeth.
• Upper laterals are often proclined, mesially tipped
and mesiolabially rotated (lower lip fails to cover • Bracket prescription: A high torque option is pre-
shorter crown). ferred for the upper central incisors due to the de-
gree of retroclination of the upper incisors.
• Deep bite (Brezniak et al., 2002) with reduced over-
jet and extruded upper incisors. Treatment options
• Buccal segments are Class II, These include:
• Scissor bite is common in the premolar region due • No treatment.
to the transverse discrepancy.
• Orthognathic surgery: When the skeletal discrepan-
•
Upper central incisors demonstrate increased cy is severe, i.e. ANB>9° in a non-growing patient,
crown-root angles (Collum angle) which indicates orthodontics combined with orthognathic surgery is
an excessive palatal “bend” of the crown (Feres et al., the preferred option.
2018).
• Orthodontic camouflage: Orthodontic treatment
• Incisors may be thin with a poorly defined cingulum of a Class II Division 2 malocclusion is known to
(Robertson and Hilton, 1965). be difficult and prone to relapse (Canut and Arias,
1999). The following appliances can be used:
Justification for treatment
1. Upper removable appliance (URA): URA is usually com-
These include:
bined with low pull headgear (supported by molar bands)
• Aesthetics improvement. and/ or anterior bite plane to limit incisor eruption and al-
• To eliminate traumatic bite that is potentially result- low lower molars to erupt. The expansion and labial segment
ing in stripping of upper palatal gingiva due to trau- alignment appliance (ELSSA) is used primarily to align and
matic occlusion with the palate and/ or recession of procline the upper labial segment in Class II cases before
lower labial mucosa, due to upper incisors imping- functional appliance therapy (Dyer et al., 2001).
ing on the gums of the lower labial segment from the 2. Functional appliances: A modified twin block with an
labial aspect, or anterior screw, double cantilever spring, Z or double springs
• To improve tooth alignment, in particular the upper to procline the maxillary incisors and to correct the sagittal
lateral incisors. relationship with same appliances has been suggested (Dyer
et al., 2001).
Treatment aims
3. Fixed appliances: Fixed appliances are required when
These include: bodily tooth movement is needed or there is a need to torque
• Relieve of crowding. upper incisors. Avoid extractions in low-angle cases is gen-
erally recommended as space closure can be challenging
• Level and align the arches. (Bjork and Skieller, 1972). If extraction is inevitable to relieve
• Correction of overbite and traumatic bite. crowding, preference is given to second premolar extraction
rather than first premolars to minimise retroclination of the
• Correct lower incisor edge-centroid relationship lower labial segment.
(lower incisor edge should lie anterior to the upper
root centroid) (Houston, 1989). Timing of treatment
• Normalisation of interincisal angle, often requiring These include:

intrusion and palatal root torquing of upper incisors • According to a Cochrane review, there is no evi-
(Mills, 1973). dence from clinical trials to advocate one appliance
• Correct buccal segment relationships. type over another in managing Class II Division 2
malocclusion in the children (Millett et al., 2018).
Treatment considerations
• Treatment can be commenced during the mixed

dentition to prevent deepening of the overbite using and Day, 1974).
a removable appliance. Treatment in the permanent
Aetiology
dentition usually involves growth modification, dis-
talization and less commonly, extractions. • Soft tissue factors.
Stability and retention • Dental factors.
Poor quality evidence exists about management and stabil- • Skeletal factors.
ity of Class II Division 2 malocclusion (Millett et al., 2012).
• Growth factors.
Guidelines are proposed based on current evidence:
Features of Class II Division 2 incisor relationships
• Treat in a timely manner to address overbite,
Skeletal
• Treat preferably non-extraction, and
• Usually mild Class II skeletal base but can be skeletal
• Correct edge to centroid relation and interincisal
I or III,
angle, and move upper incisors away from lower lip.
• Increased cranial base angle leading to mandibular
Proclination of lower incisors in Class II Division 2 cases
retrognathia (Hopkin et al., 1968),
An increased overbite can be corrected by proclining lower
• Longer cranial base leading to the prognathic max-
incisors as they have been trapped (Mills, 1968). Though pro-
illa,
clination of lower incisors is considered unstable, in this mal-
occlusion, it is thought to be stable. Selwyn-Barnett proposed • Decreased lower face height, gonial angle, mandib-
that as the upper incisors intrude to resolve the deep overbite, ular plane angle and skeletal deep bite (Al-Khateeb
the lower incisors take up the positions previously occupied and Al-Khateeb, 2009).
by the uppers incisors (i.e. they procline). (Selwyn-Barnett, • Maxilla may be short, broad and forward relative to
1996) mandible leading to a tendency for scissor bite.
Long-term retention plans Soft tissue
These include: • High resting lower lip line due to decrease lower
• A URA with a flat anterior bite plane (FABP) can be face height,
used to maintain overbite correction • Typically strap-like lower lip,
• Bonded retainers have been advocated. • Marked labio-mental fold.
• Some recommend bonded retainers and circumfer- • High masseteric muscle forces (Ingervall and Thi-
ential supra-crestal fibrotomy of rotated upper later- lander, 1974) (Sciote et al., 2012).
als (Edwards, 1970).
Dental
• Increase inter-incisal angle,
Exam night review
• Pronounced retroclination of the upper central inci-
• LI edges occlude palatal to the cingulum plateau of
sors (Brezniak et al., 2002),
UI with retroclined UI & overjet usually minimal/
increased (BSI, 1983). • Retroclined upper and lower incisors,
• If the overjet range of 5-7 mm & incisors are retro- • Upper laterals are often proclined, mesially tipped
clined it is known as Class II intermediate. and mesiolabially rotated (lower lip fails to cover
shorter crown),
• BSI Class II/2 classification based on incisor rela-
tionship • Deep bite (Brezniak et al., 2002) with reduced over-
jet and extruded upper incisors,
• Angle’s classification is based on the molar relation-
ship. • Buccal segments are usually Class II,
Incidence • Scissor bite is common in the premolar region due
to transverse discrepancy,
• Class II/2 rare malocclusion, 2.3% and 5% of all
malocclusions in Caucasians (Ast et al., 1965) (Mills, • Crown-root angle (Collum angle) may be increased
1966). (Feres et al., 2018),
• United Kingdom 10% (Millett et al., 2012, Foster • Incisors may be thin with a poorly defined cingulum

Timing of treatment (Robertson and Hilton, 1965).
• Cochrane review→ no evidence to recommend or References
discourage any type of orthodontic treatment to cor- AL-KHATEEB, E. A. A. & AL-KHATEEB, S. N. 2009. Anteroposte-
rect Class II/2 malocclusion in children (Millett et rior and Vertical Components of Class II division 1 and division 2
al., 2018). Malocclusion. The Angle Orthodontist, 79, 859-866.
Stability and retention AST, D. B., CARLOS, J. P. & CONS, N. C. 1965. THE PREVA-
LENCE AND CHARACTERISTICS OF MALOCCLUSION
• Treat in timely manner to address overbite. AMONG SENIOR HIGH SCHOOL STUDENTS IN UPSTATE
• Treat preferably non-extraction. NEW YORK. Am J Orthod, 51, 437-45.
• Edge to centroid relation, IIA and move upper inci- BASDRA, E. K., KIOKPASOGLOU, M. & STELLZIG, A. 2000. The
Class II Division 2 craniofacial type is associated with numerous
sors away from lower lip.
congenital tooth anomalies. Eur J Orthod, 22, 529-35.
Retain long-term BJORK, A. & SKIELLER, V. 1972. Facial development and tooth
• URA with flat anterior bite plane (FABP) with or eruption. An implant study at the age of puberty. Am J Orthod, 62,
without bonded retainer upper labial segment. 339-83.
BREZNIAK, N., ARAD, A., HELLER, M., DINBAR, A., DINTE, A.
• CSF of rotated upper laterals (Edwards, 1970).
& WASSERSTEIN, A. 2002. Pathognomonic Cephalometric Char-
acteristics of Angle Class II Division 2 Malocclusion. The Angle
Orthodontist, 72, 251-257.
dards Institution.
CANUT, J. A. & ARIAS, S. 1999. A long-term evaluation of treated
Class II division 2 malocclusions: a retrospective study model
analysis. Eur J Orthod, 21, 377-86.
DYER, F. M., MCKEOWN, H. F. & SANDLER, P. J. 2001. The
modified twin block appliance in the treatment of Class II division
2 malocclusions. J Orthod, 28, 271-80.
EDWARDS, J. G. 1970. A surgical procedure to eliminate rotational
relapse. Am J Orthod, 57, 35-46.
FERES, M. F. N., ROZOLEN, B. S., ALHADLAQ, A., ALKHADRA,
T. A. & EL-BIALY, T. 2018. Comparative tomographic study of the
maxillary central incisor collum angle between Class I, Class II,
division 1 and 2 patients. Journal of orthodontic science, 7.
FOSTER, T. D. & DAY, A. J. 1974. A survey of malocclusion and
the need for orthodontic treatment in a Shropshire school popula-
tion. Br J Orthod, 1, 73-8.
HOPKIN, G. B., HOUSTON, W. J. & JAMES, G. A. 1968. The cra-
nial base as an aetiological factor in malocclusion. Angle Orthod,
38, 250-5.
HOPKINS, G., HOUSTON, W. & JAMES, G. 1968. The cranial base
as an aetiological factor in malocclusion. Angle Orthod, 38, 250-5.
HOUSTON, W. J. 1989. Incisor edge-centroid relationships and
overbite depth. Eur J Orthod, 11, 139-43.
INGERVALL, B. & THILANDER, B. 1974. Relation between facial
morphology and activity of the masticatory muscles. J Oral Reha-
bil, 1, 131-47.
KARLSEN, A. T. 1994. Craniofacial characteristics in children with
Angle Class II div. 2 malocclusion combined with extreme deep
bite. The Angle Orthodontist, 64, 123-130.
LAPATKI, B. G., MAGER, A. S., SCHULTE-MOENTING, J. &
JONAS, I. E. 2002. The importance of the level of the lip line and

resting lip pressure in Class II, Division 2 malocclusion. J Dent Res,
81, 323-8.
MARKOVIC, M. D. 1992. At the crossroads of oral facial genetics.
Eur J Orthod, 14, 469-81.
MILLETT, D. T., CUNNINGHAM, S. J., O’BRIEN, K. D., BEN-
SON, P. E. & DE OLIVEIRA, C. M. 2012. Treatment and stability of
class II division 2 malocclusion in children and adolescents: a sys-
tematic review. Am J Orthod Dentofacial Orthop, 142, 159-169.e9.
SON, P. E. & DE OLIVEIRA, C. M. 2018. Orthodontic treatment
for deep bite and retroclined upper front teeth in children. Co-
chrane Database Syst Rev, 2, Cd005972.
MILLS, J. R. 1968. The stability of the lower labial segment. A
cephalometric survey. Dent Pract Dent Rec, 18, 293-306.
MILLS, J. R. 1973. The problem of overbite in Class II, division 2
malocclusion. Br J Orthod, 1, 34-48.
MILLS, L. F. 1966. Epidemiologic studies of occlusion. IV. The
prevalence of malocclusion in a population of 1,455 school chil-
dren. J Dent Res, 45, 332-6.
PANCHERZ, H., ZIEBER, K. & HOYER, B. 1997. Cephalomet-
ric characteristics of Class II division 1 and Class II division 2
malocclusions: a comparative study in children. Angle Orthod, 67,
111-20.
PECK, S., PECK, L. & KATAJA, M. 1998. Class II Division 2 mal-
occlusion: a heritable pattern of small teeth in well-developed jaws.
ROBERTSON, N. R. & HILTON, R. 1965. FEATURE OF THE
UPPER CENTRAL INCISORS IN CLASS II, DIVISION 2. Angle
Orthod, 35, 51-3.
SCIOTE, J. J., HORTON, M. J., ROWLERSON, A. M., FERRI, J.,
CLOSE, J. M. & RAOUL, G. 2012. Human masseter muscle fiber
type properties, skeletal malocclusions, and muscle growth factor
expression. J Oral Maxillofac Surg, 70, 440-8.
SELWYN-BARNETT, B. J. 1996. Class II/Division 2 malocclusion:
a method of planning and treatment. Br J Orthod, 23, 29-36.
SHEN, Y.-W., HSU, J.-T., WANG, Y.-H., HUANG, H.-L. & FUH,
L.-J. 2012. The Collum angle of the maxillary central incisors in
patients with different types of malocclusion. Journal of dental sci-
ences, 7, 72-76.
VAN DER LINDEN, F. P. 1983. Development of the dentition,
Quintessence Pub Co.

Class III Malocclusion
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Taimoor Khan
14
In this Chapter
1. Classification of Class III malocclusion
2. Prevalence of Class III malocclusion
3. Aetiology of Class III malocclusion
4. Clinical features of Class III malocclusion
5. Treatment options for Class III malocclusion
6. Interceptive treatment
7. Growth Modification
8. Orthodontic camouflage treatment
9. Favourable features for orthodontic camouflage
10. Guidelines for orthodontic camouflage
11. Consideration of a single lower incisor extrac
tion
12. Bracket prescription can aid camouflage of the
Class III malocclusion
13. Dental decompensation and orthognathic sur-
gery
14. Surgical options
C lass III incisors relationship means that the incisal edge of
Aetiologies of Class III malocclusion
Two significant factors have been identified in the aetiology
the mandibular incisors lies ahead of the cingulum plateau of
the maxillary incisors, according to the British Standard In- of the Class III malocclusion (Singh, 1999):
stitute (BSI) classification (BSI, 1983). While Class III molars 1. Positional cause: Due to the change in skeletal position,
relationship means that the mesiobuccal cusp of the perma- shown in cephalometric angular measurements due to altera-
nent maxillary first molar lies distal to the buccal groove of tion in growth pattern.
the permanent first mandibular molar (Cobourne and DiBi-
2. Quantitative cause: It is reflected as linear measurements
ase, 2015). Class III canine relationship means that the upper
due to a size alteration due to craniofacial overgrowth beyond
canine cusp tip lies posterior to the embrasure space between
normal limits.
the lower canine and the first premolar. The cephalometric
definition of Class III malocclusion is when the ANB angle Aetiological factors can be summarised into:
for the Caucasian population is less than 2° (Cobourne and
1. Genetic factors: Class III malocclusion is believed to be
DiBiase, 2015).
inherited genetically due to its familial tendency (Hapsburg
Classification of Class III malocclusion jaw). Mandibular prognathism can also be caused by certain
X-chromosome aneuploid conditions (abnormal number of
These include:
chromosomes in a haploid set).
• True Class III malocclusion refers to the Class III
2. Environmental factors such as (Gottlieb and Gottlieb,
buccal occlusion bilaterally, with anterior crossbite
1954):
or edge to edge incisor relationship (Cobourne and
DiBiase, 2015). • Enlarged tonsils (Proffit et al., 2006).
• Pseudo-Class III malocclusion refers to the Class 1 • Premature loss of the first molars.
skeletal relationship with bilateral buccal Class I oc-
• Macroglossia.
clusion and anterior crossbite or edge to edge incisor
relationship due to functional anterior mandibular • Cleft lip and palate and scarring secondary to cleft
displacement (Rabie and Gu, 2000). repair.
• Class III subdivision (asymmetry) refers to Class III • Disease of the pituitary gland and associated hor-
buccal occlusion on one side (subdivision) and Class monal disturbances, for example, acromegaly.
I on the other (Janson et al., 2010).
• Trauma and irregular eruption of permanent inci-
Classification Class III malocclusion based on the severity sors or loss of deciduous incisors (Gorlin et al., 1965,
Angle, 1907).
Overjet based classification (Proffit et al., 2006) include:
• Other contributing factors are the relative position
• Mild Class III- 0 mm
and size of the cranial base, maxilla, mandible and
• Moderate Class III -1 to -2mm temporomandibular articulation (Gold, 1949, Jena
et al., 2005, Hopkin et al., 1968, Battagel, 1993).
• Severe Class III -3 to -4 mm
Clinical features of Class III malocclusion
• Extreme >-4 mm
These include:
Cephalometry based classification is based on the magnitude
of the ANB angle ( Kerr et al., 1992) and includes:: 1. Skeletal features such as:
• Mild Class III >-2° • Short anterior cranial base.
• Moderate Class III -2°to -4° • Short posterior cranial base.
• Severe Class III <-4° • Maxillary retrusion (25%).
Prevalence of Class III malocclusion • Mandibular prognathism (18.7%).
Low prevalence in the western population, ranging from •
Combination of both retrognathic maxilla and
3-5% (Todd and Lader, 1991, Cobourne et al., 2012). How- prognathic mandible (22.2%).
ever, higher a prevalence has been reported in the Asian
• Anterior position of TMJ (Chen et al., 2008).
population of 13% (Xue et al., 2011). The incidence of an-
terior crossbite in the Caucasian population is around 10% • Increased mandibular length.
(O’Brien, 1994).
• Obtuse gonial angle.
134 Class III Malocclusion

• Usual skeletal Class III or Class I relationship (Guy- A. Sagittal cephalometric features (Zegan et al., 2015, San-
er et al., 1986, Cobourne and DiBiase, 2015) born, 1955)
• Increased lower facial height where mandibular • Decreased SNA angle.
prognathism is present.
• Increased SNB angle.
• Decreased lower facial height where maxillary re-
• Decreased AO-BO distance. i.e. BO ahead of AO
trusion is present.
with Wits analysis.
• Transverse skeletal discrepancy (Severt and Proffit,
• Increased SN-Pug angle.
1997).
• Decreased cranial base angle, N-S-Ba angle (Thiesen
• Mandibular asymmetry is common.
et al., 2013).
2. Dental features such as:
• Decreased anterior cranial base length, S-N.
• Class III incisor relationship (edge-to-edge incisor
• Decreased posterior cranial base length, N-Ba.
relationship, or reverse overjet) (Guyer et al., 1986,
Cobourne et al., 2012), • Increased mandibular corpus length.
• Reduced overjet. B. Vertical cephalometric features
• Class III molar relationship, but can vary. • Increased FMA.
• The range of overbite relationships can be observed. • Increased MMPA.
• Dental compensation for the skeletal Class III, i.e. • Increased anterior face height, N-Mn.
proclined maxillary incisors and retroclined man-
• Decreased saddle angle, N-S-Are angle.
dibular incisors.
• Decreased joint angle, S-are-Go angle.
• Crowding is more pronounced in the maxillary arch
if the aetiology is maxillary retrusion. • Obtuse gonial angle, Ar-Go-Mn angle.
• A Displacement is frequently observed due to den- C. Dental cephalometric features
tal interferences (edge to edge incisor relationship, • Increased UI-SN and UI-Maxillary plane angle.
or inadequate transverse relationship) (Gu and Jr,
2007). • Decreased LI-MP angle.
3. Soft tissue features (Jin-jong, 2008) such as: • Increased Holdaway ratio.
• Decreased angle of convexity; concave facial profile. D. Soft tissue cephalometric features
• The lower lip may be full with a thin upper lip (Guy- • Decreased Ls-E-line
er et al., 1986, Cobourne and DiBiase, 2015), • Increased Li-E-line.
• Hypotonicity of mentalis muscle. • Obtuse nasolabial angle.
• Increased throat length. Treatment options for Class III malocclusion
• Obtuse nasolabial angle (Singh, 1999) • Interceptive treatment (Graber et al., 2016).
4. Facial growth features such as: • Growth modification.
• Unfavourable growth • Orthodontic camouflage.
• The Mandible shows considerable variation in the • Decompensation followed by orthognathic surgery.
rate, timing and overall extent of growth.
• Orthognathic surgery followed by dentoalveolar de-
• There are also individual changes in the growth that compensation (surgery first)
contribute to the development of the malocclusion
(Cobourne and DiBiase, 2015). The most significant Interceptive treatment
increase in mandibular growth occurred in the cer- Upper removable appliance or 2 x 4 fixed appliance (2 brack-
vical maturation stage interval CS3-CS4 and a small- ets on the first molars and 4 brackets on the incisors) are in-
er amount in CS5-CS6. dicated when tipping movement is required, and the overbite
5. Cephalometric features such as: is positive. Evidence showed that fixed appliances are supe-
rior to URAs in the cost-effectiveness and treatment duration
Class III Malocclusion 135

(Wiedel and Bondemark, 2016, Wiedel et al., 2016). Fixed 2. Chin cup therapy
appliance treatment could be combined with anterior cross
Chin cup therapy is advocated for treating developing Class
elastics and/ or molar bite block disocclusion (Reynolds,
III malocclusions in the primary and early mixed dentition,
1978, Tzatzakis and Gidarakou, 2008).
where prognathic mandibular growth is mild to moderate in
Growth Modification nature (Thilander, 1965). It is not indicated for severe reverse
overjet, open bite, maxillary hypoplasia aetiology and lower
These include:
incisor compensation. A chin cup causes lingual tipping of
1. Protraction Facemask (PFM) the lower labial segment and clockwise rotation of the man-
dible.
PFM is advocated as an orthopaedic appliance for manag-
ing a Class III malocclusion in growing patients (McNamara, A variety of chin cups types are available to alter the verti-
1987, Graber et al., 2016). PFM is the appliance of choice in cal vector to manage the vertical proportions (Graber et al.,
the early mixed dentition or late primary dentition, ideally 2016). A systematic review concluded insufficient evidence-
when the permanent maxillary incisors erupt (approximately based data to make definitive recommendations about the
8 years) but to a lesser degree in patients older than 10 years chin cup treatment (Chatzoudi et al., 2014).
of age (Kim et al., 1999).
3. The Frankel III (FR-3) appliance
PFM has three essential components: an extraoral protraction
The FR-3 appliance aids to restrict the forces of the associated
mask, an intraoral bonded maxillary splint and elastics (used
soft tissue on the maxilla and transmits these forces to the
from the extraoral mask to the intraoral maxillary splint).
mandible (Graber et al., 2016). The FR-3 appliance is effective
A bonded acrylic splint expander can be added if maxillary
in the mixed-dentition period however long-term stability
constriction is present or a discrepancy between centric rela-
depends on future growth (Ko et al., 2004). Evidence shows
tion and centric occlusion.
that the FR-3 appliance might restrict mandibular growth but
Controversy exists over the requirement of RME before PFM doesn’t enhance forward movement of the maxilla (Sugawara
use. A meta-analysis found that PFM with or without RME and Mitani, 1997).
treatment is an effective early treatment method for skeletal
4. Bone anchored maxillary protraction/Bollard plates
Class III malocclusion (Zhang et al., 2015). On the other
(BAMP)
hand, another meta-analysis concluded that PFM therapy
was less effective in patients greater than 10 years of age with BAMP involves the placement of mini-plates in the infra-
a longer treatment time if RME was not used (Mandall et al., zygomatic region and the canine- lateral incisors region in
2016). the mandible. Class 3 elastics are attached to the mini-plates
to transfer force for the Class III correction (Yang et al., 2014,
A recent meta-analysis found the low quality of evidence sug-
Graber et al., 2016, Al-Mozany et al., 2017).
gesting that on a short-term basis, alternate rapid maxillary
expansion and constriction (Alt-RAMEC) combined with BAMP is commonly used at 11 years of age in girls and 12
maxillary protraction results in a more remarkable skeletal years in boys to ensure maximum bone rigidity, optimise the
sagittal improvement, with more maxillary protraction and stability of anchored plates, and reduce the risk of trauma-
less mandibular clockwise rotation when compared with the tising developing dental follicles. One of the drawbacks of
conventional approach (RME/PFM) (Almuzian et al., 2018). BAMP is the surgical invasiveness of the technique, especially
in young children (Hino et al., 2013, De Clerck et al., 2010,
A Cochrane review found that using a facemask to correct
Graber et al., 2016). There is controversy about the intraoral
prominent lower front teeth in children is effective when com-
and extraoral benefits of skeletal anchored maxillary pro-
pared with no treatment on a short-term basis (Watkinson et
traction (SAMP), including BAMP. According to a system-
al., 2013). PFM has a short-term skeletal effect and long-term
atic review by Major, greater orthopaedic changes and fewer
dentoalveolar effects (Woon and Thiruvenkatachari, 2017,
dental changes occur with SAMP (Major et al., 2012). How-
Jamilian et al., 2016). PFM seems to correct Class III discrep-
ever, another meta-analysis found that SAMP is as effective
ancies but decreases the overbite due to clockwise rotation of
as other traditional treatments, such as a PFM (Rodriguez de
the jaw (Rongo et al., 2017). Evidence showed that patients
Guzman-Barrera et al., 2017).
were also less likely to have orthognathic surgery if they had
facemask treatment at an early age, 36% compared with 66% Orthodontic camouflage treatment
of the control group (Mandall et al., 2016). The post PFM
The aims of orthodontic camouflage of a Class III malocclu-
retention phase includes a simply fixed plate, Frankel III or
sion are:
a chin cup, though a combination of these can also be used
(Almuzian et al., 2018). • Proclination of upper incisors.
• Retroclination of lower incisors.

• Protrusion of the maxilla. nation of the upper incisors and retroclination of the
lower incisors.
• Backward rotation of the mandible to decrease the
prominence of point “B”,
• Combination of the above. Bracket prescription can aid camouflage of the Class III
malocclusion
• Increase of the vertical dimension.
These include:
Favourable features for orthodontic camouflage
• High palatal root torque prescription in the upper
These include:
incisors brackets.
• Patient has completed their growth spurt.
• Labial root torque in the lower incisor brackets
• Near to normal soft tissue profile.
• Bracket modification through swapping lower ca-
• Normal or mild transverse relations. nine brackets is recommended to prevent the mesial
tipping of lower canines.
• No apparent facial asymmetry.
Dental decompensation and orthognathic surgery
• Mild skeletal discrepancy.
Indications (Graber et al., 2016) such as:
• Adequate vertical relationship and decreased over-
bite. • No residual growth, i.e. in late teens.
• In the absence of displacement, the patient can • Severe Class III malocclusion where orthodontic
achieve edge to edge bite in RCP. camouflage is not possible.
• Minimal dento-alveolar compensation. • Significant vertical or transverse discrepancies.
• Mild lower arch crowding (allowing extraction ther- Surgical options are:
apy to correct the overjet).
• Mandibular surgeries include bilateral sagittal split
Guidelines for orthodontic camouflage osteotomy or vertical sub-sigmoid ramus osteotomy
to reposition the mandible posteriorly for cases with
These include:
mandibular prognathism.
• The upper incisors should not be proclined beyond
• Maxillary surgeries include Le-Fort I or modified
120° to the maxillary plane (Burns et al., 2010).
Le-Fort I advancement for cases with maxillary skel-
• The lower incisors should not be retroclined less etal retrusion.
than 80° to the mandibular plane to avoid bone fen-
• Bimaxillary osteotomy may be used simultaneously
estrations and gingival recession, particularly in the
in instances of maxillo-mandibular skeletal imbal-
thin gingival biotypes (Burns et al., 2010).
ances.
• If extractions are indicated to relieve crowding in
the lower arch, extractions of anterior teeth are pre-
ferred to aid retraction of the lower labial segment.
• If extractions are indicated in the upper arch, ex- Exam night review
tractions of posterior teeth are preferred to prevent
• BSI classification→ Class III malocclusion incisal
retraction of the upper labial segment.
edges of the mandibular incisors lie ahead of the cin-
• Occlusal stability is greater if a positive overbite gulum plateau of the maxillary incisors (BSI, 1983).
is achieved at the end of the treatment and future
• Class III molar relationship→MB cusp of U6 lies dis-
growth is minimal.
tal to BG of L6 (Cobourne and DiBiase, 2015).
Consideration of a single lower incisor extraction
• Class III canine relationship→long axis of the upper
These include: canine lies or occludes distal to the embrasure of the
lower mandibular canine and the first premolar.
• To facilitate retroclination of the lower incisors, clos-
ing space on an under-sized rectangular or round
• Class III ANB 2° Caucasian (Cobourne and DiBi-
stainless steel wire is favourable.
ase, 2015).
• Class 3 elastics may be required to facilitate procli-
Classification of Class III malocclusion

• True Class III • Retroclination of the lower incisors.
• Pseudo-class III (Rabie and Gu, 2000). • Protrusion of maxilla.
• Class III subdivision (Janson et al., 2010). • +ve rotation of mandible → prominence of point
Prevalence of Class III malocclusion “B”.
• Western population 3-5% (Todd and Lader, 1991, Favourable features for Orthodontic camouflage (Co-
Cobourne et al., 2012). bourne and DiBiase, 2015)
• 13% Asian population (Xue et al., 2011). Anterior • The patient completed a growth spurt.
crossbite Caucasians 10% (O’Brien, 1994). • Near to normal soft tissue profile.
Aetiology of Class III malocclusion • Normal or mild transverse relations.
1. Genetic factors • No obvious facial asymmetry.
2. Environmental factors • Mild skeletal discrepancy.
• Enlarged tonsils (Proffit et al., 2006). • Adequate vertical relationship and average overbite.
• Premature loss of the first molars, • In the absence of displacement, the patient can
• Macroglossia, achieve edge to edge bite in RCP.
• Cleft lip and palate and scarring secondary to cleft • Minimal dento-alveolar compensation.
repair, • Mild lower arch crowding to optimise the uses of ex-
• Disease of the pituitary gland and the associated traction spaces to correct the overjet.
hormonal disturbances Guidelines for Orthodontic camouflage
• Trauma and irregular eruption of permanent inci- • UI 120° to PP
sors or loss of deciduous incisors (Gorlin et al., 1965,
Angle, 1907), • LLS 80° to MP
• Other factors (Gold, 1949, Jena et al., 2005, Hopkin • lower single incisor extraction to retrocline LLS.
et al., 1968, Battagel, 1993) • For retroclination of LI, closing space on an under-
Classification of the severity of Class III Malocclusion sized rectangular or round stainless steel wire.
mild >-2 , moderate -2°to -4°,severe: <-4° • Class 3 elastics to procline UI & retrocline LI.
Treatment options • To camouflaging, +ve torqued UI brackets & -ve

torqued LI brackets along with swapping of lower
• Interceptive treatment (Graber et al., 2016). canine brackets.
• Growth modification. • Stability→ overbite & future growth.
• Orthodontic camouflage.
• Decompensation followed by orthognathic surgery.
• Orthognathic surgery followed by dentoalveolar de-
compensation (surgery first)
Growth Modification
• Protraction Facemask (PFM)
• Chin cup therapy
• The Frankel III (FR-3) appliance:
• Bone anchored maxillary protraction/Bollard plates
(BAMP)
Aims of orthodontic camouflage treatment
• Proclination of the upper incisors.

References Components of Class III Malocclusion in Juveniles and Adoles-
cents. The Angle Orthodontist, 56, 7-30.
AL-MOZANY, S. A., DALCI, O., ALMUZIAN, M., GONZALEZ,
C., TARRAF, N. E. & ALI DARENDELILER, M. 2017. A novel HINO, C. T., CEVIDANES, L. H., NGUYEN, T. T., DE CLERCK,
method for treatment of Class III malocclusion in growing patients. H. J., FRANCHI, L. & MCNAMARA JR, J. A. 2013. Three-dimen-
Prog Orthod, 18, 40. sional analysis of maxillary changes associated with facemask and
rapid maxillary expansion compared with bone-anchored maxil-
ALMUZIAN, M., MCCONNELL, E., DARENDELILER, M. A.,
lary protraction. American Journal of Orthodontics and Dentofa-
ALHARBI, F. & MOHAMMED, H. 2018. The effectiveness of
cial Orthopedics, 144, 705-714.
alternating rapid maxillary expansion and constriction combined
with maxillary protraction in the treatment of patients with a class HOPKIN, G., HOUSTON, W. & JAMES, G. 1968. The cranial base
III malocclusion: a systematic review and meta-analysis. Journal of as an aetiological factor in malocclusion. The Angle Orthodontist,
Orthodontics, 45, 250-259. 38, 250-255.
ANGLE, E. 1907. Malocclusion of the Teeth, Philadelphia, The SS JAMILIAN, A., CANNAVALE, R., PIANCINO, M. G., ESLAMI,
White Dental Mfg. Co. S. & PERILLO, L. 2016. Methodological quality and outcome of
systematic reviews reporting on orthopaedic treatment for class
BATTAGEL, J. M. 1993. The aetiological factors in Class III maloc-
III malocclusion: Overview of systematic reviews. J Orthod, 43,
clusion. The European Journal of Orthodontics, 15, 347-370.
102-20.
JANSON, G., DE FREITAS, M. R., ARAKI, J., FRANCO, E. J. &
dards Institution.
BARROS, S. E. C. 2010. Class III subdivision malocclusion cor-
BURNS, N. R., MUSICH, D. R., MARTIN, C., RAZMUS, T., GU- rected with asymmetric intermaxillary elastics. American Journal
NEL, E. & NGAN, P. 2010. Class III camouflage treatment: what of Orthodontics and Dentofacial Orthopedics, 138, 221-230.
are the limits? Am J Orthod Dentofacial Orthop, 137, 9.e1-9.e13;
JENA, A., DUGGAL, R., MATHUR, V. & PARKASH, H. 2005.
discussion 9-11.
Class-III malocclusion: Genetics or environment? A twins study.
CHATZOUDI, M. I., IOANNIDOU-MARATHIOTOU, I. & Journal of Indian Society of Pedodontics and Preventive Dentistry,
PAPADOPOULOS, M. A. 2014. Clinical effectiveness of chin cup 23, 27.
treatment for the management of Class III malocclusion in pre-
JIN-JONG, L. J. 2008. Creative orthodontics: Blending the Damon
pubertal patients: a systematic review and meta-analysis. Progress
system and Tads to manage difficult malocclusions. American Jour-
in orthodontics, 15, 62-62.
nal of Orthodontics and Dentofacial Orthopedics, 133, 923.
CHEN, F., TERADA, K., YANG, L. & SAITO, I. 2008. Dental arch
KIM, J. H., VIANA, M. A., GRABER, T. M., OMERZA, F. F. &
widths and mandibular-maxillary base widths in Class III maloc-
BEGOLE, E. A. 1999. The effectiveness of protraction face mask
clusions from ages 10 to 14. American Journal of Orthodontics and
therapy: a meta-analysis. Am J Orthod Dentofacial Orthop, 115,
Dentofacial Orthopedics, 133, 65-69.
675-85.
KO, Y.-I., BAEK, S.-H., MAH, J. & YANG, W.-S. 2004. Determi-
nants of successful chincup therapy in skeletal class III malocclu-
COBOURNE, M. T., FLEMING, P. S., DIBIASE, A. T. & AHMAD, sion. American journal of orthodontics and dentofacial orthope-
S. 2012. Clinical cases in orthodontics, John Wiley & Sons. dics, 126, 33-41.
DE CLERCK, H., CEVIDANES, L. & BACCETTI, T. 2010. Dento- MAJOR, M. P., WONG, J. K., SALTAJI, H., MAJOR, P. W. &
facial effects of bone-anchored maxillary protraction: a controlled FLORES-MIR, C. 2012. Skeletal anchored maxillary protraction for
study of consecutively treated Class III patients. American Journal midface deficiency in children and early adolescents with Class III
of Orthodontics and Dentofacial Orthopedics, 138, 577-581. malocclusion: A systematic review and meta-analysis. Journal of
the World Federation of Orthodontists, 1, e47-e54.
GOLD, J. K. 1949. A new approach to the treatment of mandibular
prognathism. Am J Orthod, 35, 893-912, illust. MANDALL, N., COUSLEY, R., DIBIASE, A., DYER, F., LITTLE-
WOOD, S., MATTICK, R., NUTE, S. J., DOHERTY, B., STIVA-
GORLIN, R. J., REDMAN, R. S. & SHAPIRO, B. L. 1965. Effect
ROS, N., MCDOWALL, R., SHARGILL, I. & WORTHINGTON,
of X-chromosome aneuploidy on jaw growth. Journal of dental
H. V. 2016. Early class III protraction facemask treatment reduces
research, 44, 269-282.
the need for orthognathic surgery: a multi-centre, two-arm parallel
GOTTLIEB, I. & GOTTLIEB, O. 1954. Mandibular protrusion in randomised, controlled trial. Journal of Orthodontics, 43, 164-175.
edentulous patients. Oral Surg Oral Med Oral Pathol, 7, 813-21.
MCNAMARA, J. J. 1987. An orthopedic approach to the treatment
GRABER, L. W., VANARSDALL, R. L., VIG, K. W. & HUANG, G. of Class III malocclusion in young patients. Journal of clinical
J. 2016. Orthodontics-e-book: current principles and techniques, orthodontics: JCO, 21, 598-608.
Elsevier Health Sciences.
O’BRIEN, M. 1994. Children’s dental health in the United Kingdom
GU, Y. & JR, J. A. M. 2007. Mandibular Growth Changes and Cer- 1993, HMSO.
vical Vertebral Maturation. The Angle Orthodontist, 77, 947-953.
PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
GUYER, E. C., III, E. E. E., JR., J. A. M. & BEHRENTS, R. G. 1986. temporary orthodontics, Elsevier Health Sciences.

RABIE, A. & GU, Y. 2000. Diagnostic criteria for pseudo–Class III fixed or removable appliances. Angle Orthod, 86, 324-30.
malocclusion. American Journal of Orthodontics and Dentofacial
WIEDEL, A. P., NORLUND, A., PETRÉN, S. & BONDEMARK, L.
2016. A cost minimisation analysis of early correction of anterior
REYNOLDS, I. 1978. The anterior crossbite. A simple method of crossbite-a randomised controlled trial. Eur J Orthod, 38, 140-5.
treatment. British dental journal, 144, 143.
WOON, S. C. & THIRUVENKATACHARI, B. 2017. Early orth-
RODRIGUEZ DE GUZMAN-BARRERA, J., SAEZ MARTINEZ, odontic treatment for Class III malocclusion: A systematic review
C., BORONAT-CATALA, M., MONTIEL-COMPANY, J. M., and meta-analysis. Am J Orthod Dentofacial Orthop, 151, 28-52.
PAREDES-GALLARDO, V., GANDIA-FRANCO, J. L., ALM-
XUE, S. A., LAM, C. W.-Y., WHITEHILL, T. L. & SAMMAN, N.
ERICH-SILLA, J. M. & BELLOT-ARCIS, C. 2017. Effectiveness
2011. Effects of Class III malocclusion on young male adults’ vocal
of interceptive treatment of class III malocclusions with skeletal
tract development: a pilot study. Journal of Oral and Maxillofacial
anchorage: A systematic review and meta-analysis. PLoS One, 12,
Surgery, 69, 845-852.
e0173875.
YANG, X., LI, C., BAI, D., SU, N., CHEN, T., XU, Y. & HAN, X.
RONGO, R., D’ANTO, V., BUCCI, R., POLITO, I., MARTINA, R.
2014. Treatment effectiveness of Fränkel function regulator on
& MICHELOTTI, A. 2017. Skeletal and dental effects of Class III
the Class III malocclusion: a systematic review and meta-analysis.
orthopaedic treatment: a systematic review and meta-analysis. J
Oral Rehabil, 44, 545-562.
146, 143-154.
SANBORN, R. T. 1955. Differences between the facial skeletal pat-
ZEGAN, G., DASCALU, C., RADU, M. & ANISTOROAEI, D.
terns of Class III malocclusion and normal occlusion. The Angle
2015. CEPHALOMETRIC FEATURES OF CLASS III MALOC-
CLUSION.
SEEHRA, J., FLEMING, P., MANDALL, N. & DIBIASE, A. 2011. A
ZHANG, W., QU, H.-C., YU, M. & ZHANG, Y. 2015. The Effects of
comparison of two different techniques for early correction of Class
Maxillary Protraction with or without Rapid Maxillary Expansion
III malocclusion. The Angle orthodontist, 82, 96-101.
and Age Factors in Treating Class III Malocclusion: A Meta-Analy-
SEVERT, T. & PROFFIT, W. 1997. The prevalence of facial asym- sis. PloS one, 10, e0130096-e0130096.
metry in the dentofacial deformities population at the University
of North Carolina. The International journal of adult orthodontics
and orthognathic surgery, 12, 171-176.
SINGH, G. 1999. Morphologic determinants in the etiology of class
III malocclusions: a review. Clinical Anatomy: The Official Journal
of the American Association of Clinical Anatomists and the British
Association of Clinical Anatomists, 12, 382-405.
SUGAWARA, J. & MITANI, H. Facial growth of skeletal class
IIImalocclusion and the effects, limitations, and long-term dento-
facial adaptations to chincap therapy. Seminars in Orthodontics,
1997. Elsevier, 244-254.
THIESEN, G., PLETSCH, G., ZASTROW, M. D., VALLE, C. V. M.
D., VALLE-COROTTI, K. M. D., PATEL, M. P. & CONTI, P. C. R.
2013. Comparative analysis of the anterior and posterior length and
deflection angle of the cranial base, in individuals with facial Pat-
tern I, II and III. Dental Press Journal of Orthodontics, 18, 69-75.
THILANDER, B. 1965. Chin-cap treatment for Angle Class 3 mal-
occlusion. Rep Congr Eur Orthod Soc, 41, 311-27.
TODD, J. E. & LADER, D. 1991. Adult dental health 1988 United
Kingdom, HM Stationery Office.
TZATZAKIS, V. & GIDARAKOU, I. K. 2008. A new clinical ap-
proach for the treatment of anterior crossbites. World journal of
orthodontics, 9.
WATKINSON, S., HARRISON, J. E., FURNESS, S. &
WORTHINGTON, H. V. 2013. Orthodontic treatment for
prominent lower front teeth (Class III malocclusion) in children.
Cochrane Database Syst Rev, Cd003451.
WIEDEL, A. P. & BONDEMARK, L. 2016. A randomised con-
trolled trial of self-perceived pain, discomfort, and impairment of
jaw function in children undergoing orthodontic treatment with

Transverse arch
discrepancY
15
Written by: Mohammed Almuzian, Haris Khan, Maham Munir, Abbas Naseemn
In this Chapter
1. Types of maxillary skeletal deficiency 20. Interpretation mid-palatal suture maturation
2. Benefits of treating displacement classification:
3. Incidence of transverse maxillary deficiency 21. Mid-palatal suture density ratio
4. Age-related changes in maxillary dimension 22. Protocols of maxillary expansion
5. Aetiology of transverse maxillary deficiency 23. Modern designs of RME/ Mini-implant assisted
rapid palatal expansion (MARPE)
6. Clinical features of transverse maxillary defi
ciency 24. Surgical maxillary expansion
7. Diagnosis of transverse maxillary deficiency 25. Indications for SARPE
8. Treatment objectives 26. Complications during SARPE
9. How much expansion is required? 27. Retention and stability secondary to MPMO
10. Non-surgical maxillary expansion 28. Factors & Yardsticks
11. Principle of RME 29. Appliances for unilateral maxillary expansion
12. The rationale for expansion treatment 30. Treatment of scissor bite
13. Types of conventional RME 31. Stability and retention of expansion
14. The influence of the height of RME 32. Anterior crossbites
15. Proposed Indications for RME 33. Requirement for the successful result using URA
16. Contraindications and limitations of conven 34. EXAM NIGHT REVIEW
tional RME
17. Potential complications of RME
18. Mid-palatal suture assessment methods
19. Mid-palatal suture maturation classifica-
tion
T ransverse maxillary deficiency is defined as a constricted
first mandibular molars or the distance between the
most cervical extension of the buccal grooves on the
maxilla relative to the mandible (Proffit et al., 2006). It can mandibular first molars (Garino and Garino, 2002).
manifest with the following:
• Palatal width: Minimum distance at the gingival lev-
• Anterior crossbite: The upper anterior teeth are palatally el between maxillary first molars (Lux et al., 2003) or
positioned in their relationship to the lower anterior the distance between the mesio-lingual cusp tips of
teeth (Prakash and Durgesh, 2010). the first molars (Isaacson et al., 1971).
• Posterior crossbite: In centric relation, the upper poste- • Trans-palatal width: The distance between the right
rior teeth are palatal relative to the opposing lower pos- and left gingival ends of the palatal grooves of the
terior teeth. This is the most common type of crossbite maxillary first molars.
(Andrade et al., 2009).
• Telescopic bite: Bilateral mandibular lingual cross-
When there is a discrepancy, the mandible encounters a de- bite. The mandibular posterior teeth are lingual to
flecting contact, which is displaced. Displacements can be the maxillary teeth.
anterior, posterior or lateral.
• Brodie bite: Unilateral or bilateral complete poste-
Different terminologies in transverse maxillary deficiency rior buccal crossbite, also called Brodie syndrome.
These include: It is a severe transverse discrepancy when all buccal
cusps of the lower molars are telescoped within the
• Crossbite: A discrepancy of the tooth relationship in lingual cusps of the upper molars (Valencia, 2007).
the transverse plane of space (BSI, 1983). Incidence is around 1.0% to 1.5%.
• Buccal crossbite: The buccal cusps of the mandibu- Types of maxillary skeletal deficiency
lar teeth occlude laterally or buccally to the buccal
cusps of the maxillary teeth (BSI, 1983). There are two types of maxillary skeletal deficiency (Haas,
1965, Kutin and Hawes, 1969):
• Lingual crossbite: The buccal cusps of the mandibu-
lar teeth occlude lingually to the palatal cusps of the • Relative maxillary deficiency: when the maxilla is
maxillary teeth. of normal size compared to the upper face and the
cranium, the mandible is comparatively large.
• Unilateral crossbite: Crossbite affects one side of the
dental arch, which may or may not be associated • Real maxillary deficiency: The maxilla size is small
with functional mandibular displacement (Palla and compared to the mandible and midface. Upper
N, 2018). posterior teeth can either be on the basal bone or
inclined buccally to occlude the mandibular teeth
• Bilateral crossbite: Both sides of the dental arch are (transverse compensation).
affected and are in crossbite.
• Haas introduced the terms relative and absolute
• Crossbite tendency: The tooth-to-tooth contact in transverse discrepancy (Haas, 1961):
the transverse plane are in edge to edge relationsip
in the occlusion (Grammatopoulos et al., 2012). • Relative transverse discrepancy: This is due to an-
tero-posterior positioning of the mandible.
•
Displacement: The functional deflection of the
mandible on closing from retruded contact position • Absolute transverse discrepancy exists when the
(RCP) to the intercuspal position (ICP). There is a posterior teeth do not coordinate in centric relation
discrepancy between the muscular positioning of or on dental models when canines are placed into a
the mandible (centric position) and that dictated by Class I relationship.
the teeth coming into the occlusion (centric occlu- Benefits of treating displacement
sion) (Cobourne et al., 2012).
These include:
• Upper inter-molar width: The distance between the
mesiobuccal cusps tips of the right and left maxillary • Aesthetic benefits by widening the buccal corridor
first molars (Garino and Garino, 2002), or the dis- • Eliminate the undesirable growth, which can result
tance between the central fossae of the permanent in mandibular displacment and eventually to true
maxillary molars on the right and left sides (Lux et mandibular asymmetry
al., 2003).
• Potentially avoid TMD in the susceptible patient
• Lower inter-molar width: The distance between the (weak evidence)
cusp tips of the distobuccal cusps of the right and left
142 Maxillary Transverse Arch Discrepancy

• Avoid exacerbation of plaque related periodontal • Habits such as thumb sucking
damage.
• Trauma or pathology
• Avoid tooth surface loss.
• Obstruction of the upper airway due to the enlarged
Incidence of transverse maxillary deficiency adenoids
The incidence of transverse maxillary deficiency is 8-22% • Nasal allergies
(Andrade et al., 2009), while the prevalence of posterior
• Mouth breathing during growing years
crossbite is 7.7%. Moreover, the prevalence of anterior cross-
bite is 10 % (Allen et al., 2003, O’Brien, 1994). Functional • Cleft lip and palate
mandibular displacement towards the crossbite is found in
• Arch length discrepancy and crowding
80-97% of the cases (Thilander et al., 1984).
• Over-retained or an early loss of deciduous teeth
Age-related changes in maxillary dimension
• Abnormal tooth anatomy
Arch dimensions change with growth. It is, therefore, nec-
essary to distinguish changes induced by appliance therapy • Iatrogenic causes, for example, surgical correction
from those that occur from natural growth. Both upper and of the cleft lip and palate.
lower inter-canine widths increase from the 6th year up to 13 Clinical features of transverse maxillary deficiency
years in both genders, increasing more prominent in the up-
per arch. From 13 to 45 years, inter-canine widths decrease. Transverse maxillary deficiency has the following common
clinical manifestations (McNamaraa, 2000):
Maxillary and mandibular inter-molar widths continue to
increase until the age of 13 in both genders. However, there • Upper arch crowded.
is a slight decrease in widths for females from periods 13-45 • Unilateral or bilateral crossbite with or without
years with no change in male inter-molar width (Bishara et functional jaw displacement.
al., 1997).
• Buccally flared upper posterior teeth.
Bjork’s study
• Wide buccal corridors.
• Inter-canine width increases until the full eruption
of the permanent incisors, after which there is a con- • Narrow and high palatal vault. (Proffit et al., 2006).
tinuous decrease up to adult age. • ‘V’ or triangular shaped maxilla.
• Mid-palatal growth was found to cease by the age of • Impacted teeth due to constricted anterior maxilla
17 years. (McConnell et al., 1996).
• Posterior maxillary growth was more than anterior Diagnosis of transverse maxillary deficiency
growth with transverse rotation (Björk and Skieller,
1974). These include:
Other studies showed that: 1. Recording functional jaw displacement: Record any func-
tional jaw displacement from RCP to ICP in direction and
• Transpalatal width increased only 2.6 mm from age quantity. Absence of displacement indicates that the crossbite
7 to 15. After 12 years of age, there is no change for is of a skeletal origin (Piero, 2006).
females and very little increase (about 1mm) for
males in both maxilla and mandible (McNamara et 2. Study model measurements: Measure the palatal width
al., 2001) (X) and the lower inter-molar width (Y) on the study model
(Proffit et al., 2006). Distances between the midpoint of teeth
• The inter-canine widths of upper and lower arches could be measured in mm and compared to a tabulated tem-
tend to decrease slightly during the permanent den- plate (Moyers, 1976).
tition (around 12 years old) for both males and fe-
males (Bishara et al., 1997). 3. Radiography: A Posterior-Anterior (PA) cephalogram or
CBCT can be used to calculate transverse skeletal discrep-
Aetiologies of transverse maxillary deficiency ancies between the maxilla and the mandible (Allen et al.,
The causes of maxillary constriction may include dental, soft 2003). The following measurements can be recorded:
tissue and skeletal components and are listed below (Allen et • Effective maxillary width (JL-JR): The distance be-
al., 2003, Andrade et al., 2009): tween JL and JR (bilateral points located at a depth
• Hereditary of concavity of the lateral maxillary contour, at the
junction of the maxilla and zygomatic buttress).
Maxillary Transverse Arch Discrepancy 143

• Effective mandibular width (AG-GA): The distance ing patients (Suri and Taneja, 2008).
between AG and GA points (bilateral points at the
Non-surgical maxillary expansion
inferior margin of the antegonial protuberance).
1. Removable expansion appliances such as:
•
Maxillomandibular transverse differential: The
maxillomandibular differential width (Ag-Ag and A. Upper removable appliance with expansion screw (Almu-
J-J) compared with Ricketts’ normal values of the zian et al., 2016, Gill et al., 2004): A slow maxillary expander
same age. A difference within 5mm is average; how- consists of an upper acrylic removable appliance, incorporat-
ever, a transverse skeletal problem exists if it is more ing a midline expansion screw. Retention can be achieved us-
than 5mm. The Maxillomandibular transverse dif- ing Adam’s clasps on premolars and first molars. A posterior
ferential limitations are significant errors in land- bite plane is added for bite raising if required. The appliance
mark identification of point Ag and J (Chung, 2019) produces mostly dento-alveolar expansion by tipping molar
and no consensus transverse norm values. teeth buccally with little skeletal effect. For symmetrical ex-
pansion (most common), the baseplate of the appliance is di-
CBCT evaluation
vided, with an equal number of anchor molars on either side
With the advent of cone-beam computed tomography of the midline. Theoretically, asymmetric expansion can be
(CBCT), the following can be accurately determined to assess undertaken by incorporating more teeth on the anchor side
in diagnosis and treatment planning: and less on the movement side. After expansion, the appli-
ance should remain passive for 3 - 4 months for retention.
• Widths of maxillary and mandibular basal bones
and their relationship. B. Upper removable appliance with Coffin spring: A 1.25
mm round stainless-steel wire is incorporated in the design
• Buccolingual inclination of each tooth.
of the upper removable appliance. The spring is either bent
• Root position in the alveolar bone. into an Omega-loop or a diamond shape; hence, it is some-
times called an Egg-shape appliance. The appliance is acti-
Treatment objectives
vated by pulling the two halves of the appliance apart by 2
The following treatment objectives should be considered – 3 mm. Adam’s plier could also be used for activation of the
(Chung, 2019): central loop.
• The maxillary basal bone should be expanded to the C. Functional appliances: This can be achieved either by ac-
point that the palatal cusps of maxillary molars oc- tive expansion, usually with expansion screw or palatal arch,
clude beyond the central fossae of mandibular mo- or by passive expansion by removing buccal tissues’ influence
lars. with buccal shields (Frankel appliance).
• Normal curve of Wilson should be achieved for the Pros and cons of removable expanders
ideal occlusal function. However, excess in the curve
These include:
of Wilson results in occlusal interferences (Nanda,
2005). • They can easily incorporate other active compo-
nents such as springs,
How much expansion is required?
• Expansion component can be part of a functional
Generally, the required amount of expansion is the differ-
appliance such as a twin block.
ence between the buccal cusp widths of lower molars and
the central fossa widths of the upper molars; the normal val- • They rely on patient compliance.
ues are +1.6mm for males and +1.2mm for females (Chung,
• It is a less well-tolerated appliance with poor reten-
2019). Ideally, molars should be over-expanded by 2 to 4mm
tion.
to compensate for the expected post-expansion relapse. To-
tal expansion includes skeletal expansion (true mid-palatal • They produce mainly dental changes.
suture expansion) and/ or dental expansion (dental tipping
• As buccal tipping of the molars occurs, the palatal
and alveolar bone bending) (Zong et al., 2019). The follow-
cusps tend to drop down, and this can cause overbite
ing treatment modalities have been suggested based on the
reduction and increase of the MMPA.
degree of the discrepancy:
• Expansion is mainly dento-alveolar.
• 2-3mm = Upper removeable
2. Fixed expansion appliances such as:
• 4-5mm = Quad-helix
A. Quadhelix appliance: It can be custom made or a pre-
• 5-6mm = RME (growing patients)
formed ready type. The device is fabricated from 1.0-0.9 mm
• More than 6mm = MARPE or SARPE in non-grow- stainless steel wire. It incorporates four helices into the ‘W-

spring’, which increases the flexibility and range of activation • It has a bite opening effect.
by increasing the length of the spring’s wire. Molar bands are
• Sometimes, the appliance can imprint the tongue;
used for retaining the appliance on the first molars with glass
however, this will rapidly disappear following treat-
ionomer cement. Quadhelix consists of anterior helices and
ment.
a pair of posterior helices. The wire portion between the two
anterior helices is called the anterior bridge, and the wire be- C. Expansion (E) Arch (McNally et al., 2005): It is also called
tween the anterior and posterior helices is called the palatal Mulligan overlay archwire. In principle, it is similar to the first
bridge. The free wire ends adjacent to the posterior helices are E-arch, which Edward Angle introduced in 1887. The expan-
called outer arms. Different versions of the Quadhelix have sion arch is made of round stainless-steel wire (1.135 mm),
been proposed. The nickel-titanium versions have been in- bent into a wide dental arch. It is inserted into the headgear
troduced, offering more favourable force delivery character- tubes on the upper first molar bands or positioned over the
istics. Bi-helix design can expand the narrowed or distorted main archwire ligated in place. According to a randomised
mandibular arch to aid correction of a severe scissors bite. control trial, both the quad-helix and the expansion arch
Before bone grafting, the trihelix design is used as an expan- were equally effective in the expansion if similar force levels
sion appliance in the cleft palate. In pre-pubertal children, were used. Quadhelix causes discomfort to the tongue while
Quadhelix produces 6:1 buccal tipping to skeletal expansion. the expansion arch interferes with the cheeks. However, the
expansion arch has the advantage of being cheap and requir-
B. Activation is undertaken either with manual stretching
ing less chair-side time to place than Quadhelix (McNally et
of the appliance or using a three-prong plier. A desirable
al., 2005).
force level of 300-400 grams/ side is usually achieved when
activating half a tooth’s width on each side. However, over- 3. Fixed appliances expansion techniques: Expansion can
correction is desirable. It is advisable to retain the corrected be obtained during fixed appliance treatment in a variety of
results for 3 months using either the same appliance in a pas- ways, including:
sive mode, upper removable appliance or TPA with extended
• The use of overexpanded stainless steel archwires,
arms. A Cochrane review concluded that a quad‐helix is 20%
typically using 0.019 x 0.025 or 0.021 x 0.025 with
superior to removable expansion appliances (1.15 mm more
reduced progressive buccal root torque.
expansion) in correcting posterior crossbites in children aged
8-10 years (Agostino et al., 2014). Another systematic review • Cross elastics run from the palatal aspect of upper
found a greater success rate and compliance using a quad- teeth to the buccal aspect of lower teeth. However,
helix when compared to removable appliances (Zuccati et al., there will also be a vertical component of a force that
2013). will tend to extrude molars; therefore, it is contrain-
dicated in high angle cases.
Advantages of Quadhelix appliance
4. Rapid Maxillary Expansion RME (Maxillary suture ex-
These include:
pander)
• It has optimum retention.
Principle of RME
• No compliance is needed.
Skeletal expansion treatment involves mid-palatal suture sep-
• It has a good range of activation. aration and widening the palatal shelves, which widens the
floor of the nose and roof of the mouth. The palatal expansion
• It can derotate molars.
can be performed at any time before the completion of the
• It can be used as a habit breaker. growth spurt (CVMS2 and CVMS3). Later, with age increase,
the mid-palatal suture becomes more tightly interdigitated,
• It can expand the upper arch anteroposteriorly when
forcing relatively heavy forces to separate.
its arm’s length increases.
The rationale for expansion treatment
• It can provide anchorage in AP and transverse di-
rections. The effects of RME in achieving maxillary expansion are:
• It can be a method for attachments to align impact- • Buccal tipping or bodily movement of the teeth
ed teeth or perform certain teeth movement.
• Alveolar bone bending due to the resilient nature of
Disadvantages of Quadhelix appliance the alveolar bone
These include: • Separation of the mid-palatal suture, with induction
of new bone formation.
• Little orthopedic change can be achieved.
The relative amounts of these changes vary depending on the
• It mainly produces the tipping of molars.
type of appliance used, rate of activation, and the patient’s

age. These effects can be achieved by using a rigid appliance the screw or acrylic capping of the posterior denti-
(to limit tipping of the molars) and applying heavy and rapid tion and acrylic connector to the screw. This design
forces (to exceed the rate of dental movement and produce is associated with an increased risk of decalcifica-
splitting of the suture). The midpalatal suture opening is fan- tion.
shaped or triangular with a maximum opening at the incisor
The influence of the height of RME
region but gradually diminishing towards the posterior part
of the palate. The fan-shaped or non-parallel opening is also If the the screw is close to the palate, an extrusive tenden-
seen in the superior-inferior direction. The maximum open- cies of the posterior teeth are expected when the screw
ing is towards the oral cavity, which progressively reduces in is placed above the centre of the teeth and nearer to the
the direction of the nasal aspect. palate. If the screw is away from the palate, more buccal
crown tipping is expected when the hyrax screw is far
Types of conventional RME
away from the palate.
RMEs can be divided into three types depending on how the
Proposed indications of the RME
appliance is retained (Almuzian et al., 2016):
The following are the proposed indications of the RME (Gill
a) Banded: A systematic review comparing different tooth-
et al., 2004):
borne RME appliances, 4-band appliances are indicated when
anterior crowding is present within a tapered arch. 2-band • Crossbite correction (unilateral or bilateral): The
appliances are more effective when mild crowding in the pos- short-term outcomes of RME are 4:1 skeletal to den-
terior regions is present (Zuccati et al., 2013). tal expansion, but over time, this ratio reduces to 1:1.
• Tooth-borne: e.g. HYRAX/ Biedermann and Isaac- • Broadening the smile (Moore et al., 2005).
son appliances
• In a ‘V-shaped’ arch form due to para-functional
• Tooth and tissue borne: e.g. Haas and Derichsweiler habits.
appliances
• Following Class II growth modification to correct
b) Bonded appliance: Mostly tooth-tissue borne. the relative crossbite created through advancing the
mandible relative to the maxilla.
c) Hybrid HYRAX: Tooth and bone-borne (retention from
teeth and TADs). • To facilitate maxillary protraction with protraction
facemask therapy.
Depending on the appliance design, RMEs can also be divid-
ed into (Almuzian et al., 2016): • Interceptive treatment of impacted canines (Baccetti
et al., 2011, Pavoni et al., 2013).
• HYRAX (HYgienic RApid eXpander) is a tooth-
borne appliance, and it consists of an expansion • Preparation for the grafting procedure in a cleft al-
screw that is soldered/welded to molar bands on veolus (Shaw and Semb, 1990).
abutment teeth.
• Space creation: For every 1mm of increase in the
• The Isaacson appliance is tooth-borne and also inter-molar width, there is 0.6mm of relief of crowd-
known as the ‘Minne-Expander’. It is similar to a ing and 0.3mm of overjet reduction (O’Higgins and
HYRAX appliance, except the expansion screw is Lee, 2000).
replaced with coil spring, activated by turning a key
• Expansion in conjunction with upper molar distali-
to compress the spring. The disadvantage of this ap-
sation.
pliance is that it produces a continuous force.
• Orthopaedic expansion of the narrow upper arch:
• The Haas appliance consists of an expansion screw
Conflicting evidence regarding the pattern of the
with buccal and palatal connectors from the screw
expansion is present; some authors concluded that
to a palatal plate (acrylic or metal). According to a
the expansion is pyramidal with the more anterior
randomised clinical trial comparing expansion with
expansion than posterior, while others concluded
HYRAX and a Haas appliance, the latter had a more
that the ratio of inter-canine to inter-molar width
orthopaedic effect with less tipping tendency of the
increase with RME is 0.75:1 respectively (Gopal-
maxillary first molars (Weissheimer et al., 2011).
akrishnan and Sridhar, 2017). The overall quality of
• Derichsweiler is comparable to the Haas design ex- evidence was generally low (Liu et al, 2015). A sys-
cept for the absence of buccal connectors. tematic review concluded that the effect of RME on
the mid-palatal suture ranges from 12 – 52.5% of the
• The bonded RME appliance consists of either cobalt
total screw expansion. Some authors consider RME
chrome housing of the dentition and connector to
a possible option in patients greater than 15 years of

age (Bishara and Staley, 1987, Wertz, 1970), however • Root resorption (RR): According to a systematic
according to an autopsy study of mid-palatal su- review, there is significant RR with the jack-screw
tures, most fuse by 15 years of age (Melsen, 1975). In based expander (Odenrick et al., 1991) (Forst et al.,
light of this study, RME should be prescribed before 2014). Greater RR was found to occur after tooth-
this age. tissue-borne expansion compared with bone-borne
expansion. Most RR happened at the root’s apical
• It might help improve nasal airflow in patients with
and middle thirds, with more present on the buccal
nasal obstruction (Almuzian et al., 2016). RME
than the lingual surface (Yildirim and Akin, 2019).
seems to be associated with increasing the nasal cav-
ity volume in short and long-term fields(Buck et al., • Vertical dimension changes: RME results in an in-
2017). According to a systematic review, RME im- crease in the maxillo-mandibular plane angle and an
proves nasal airflow, but it should not be used solely increase in the lower face height, which can be detri-
for this purpose (Gordon et al., 2009). A systematic mental in anterior open bite cases (Jacobson, 1991).
review showed improvement in nasal breathing is
• Scissor bite is excessive over-correction.
stable for 11 months post-treatment (Baratieri et al.,
2011). • Transient but rare complications such as pain, dis-
comfort, temporary diplopia, pressure necrosis of
• As a treatment modality for those with conduc-
palatal mucosa and inability to activate the appliance
tive hearing loss due to eustachian tube stenosis or
middle ear problems, low to moderate level evidence Mid-palatal suture assessment methods
indicates an improvement in hearing after maxillary
As described in the principle of expansion section, RME de-
expansion in children and adolescents with hearing
pends on the palatal shelves’ separation. Growth and devel-
impairments (Fagundes et al., 2017).
opment can influence this process; therefore, measures of as-
• Early correction of a posterior crossbite with func- sessment of the mid-palatal suture have been proposed:
tional displacement can prevent asymmetric growth
Mid-palatal suture maturation classification
and condyle position (English et al., 2014).
A CBCT assessment in which the mid-palatal maturation
Contraindications and limitations of conventional RME
staging is divided into 5 stages (Angelieri et al., 2013):
These include:
• Stage A: The suture is seen as a relatively straight ra-
• Uncooperative patient diopaque line.
• Adult patient • Stage B: The suture appears as a sinuous line of high
density.
• High angle & openbite tendency
• Stage C: There are 2 radiopaque, winding, and paral-
• Convex profile
lel lines separated by areas of low radiographic den-
• Severely buccally tipped teeth sity.
• In a periodontally weak dentition. • Stage D: The palatine bones become more radi-
opaque, and the suture is not seen in this area. It is
• Significant true skeletal asymmetry
still possible to observe the two parallel radiopaque
• Significant expansion required lines in the palatal area.
Potential complications of RME • Stage E: The sutures along the maxillary and pala-
tine bones are not seen, indicating suture fusion.
These include:
Interpretation mid-palatal suture maturation classifica-
• Pain and soreness: according to a randomised clini-
tion:
cal trial, most treated patients experience pain and
distress in terms of pressure sensation whilst actively • Stages A and B offer less resistance to RME; more
expanding (Halicioglu et al., 2012). skeletal effects can be achieved.
• Periodontal damage: There can be transient pulpal • Stage C is a critical stage as suture fusion is immi-
and periodontal damage, as well as minimal loss of nent, and at this stage, fewer skeletal effects are at-
alveolar bone support (Almuzian et al., 2016). A sys- tained than earlier stages, with greater dento-alveo-
tematic review found significant loss of buccal bone lar effects.
thickness and marginal bone level in anchored teeth
• Stage D and E - suture fusion has occurred, and the
following RME (Lo Giudice et al., 2018).
response to conventional RME is only dent-alveolar.

Assessment of mid-palatal suture maturation has the advan- desired expansion is achieved.
tage of avoiding complications related to maxillary expan-
2. Semi-rapid expansion
sion. Also, unnecessary SARPE procedures can be avoided.
The screw appliance is activated twice daily during the first
Mid-palatal suture density ratio (Grunheid et al., 2017)
5-6 days followed by 3 activations per week (Işeri and Ozsoy,
A CBCT assessment can determine the suture density ratio 2004) or a ¼ turn daily.
through the following terms and equations: The average gray
3. Slow Expansion
density (GDs) value is determined for a region of the suture
(GDsp) and the palatal process of the maxilla (GDppm). The screw appliance is activated at a rate of 1 mm per week,
The defined region of the suture is always determined on the one quarter turn activation every alternate day. No midline
most central axial slice through the hard palate. The following diastema appears during slow expansion, and the ratio of
equation uses the average gray density values to calculate the dental to skeletal expansion is approximately 4:1 with mini-
mid-palatal suture density (MPSD) ratio. mal tissue damage.
MPSD ratio = GDs - GDsp Slow maxillary expansion produces 2-4 pounds of force,
significantly lighter than the force generated during a rapid
GDppm - GDsp
maxillary expansion (10-20 pounds). The whole active ex-
This ratio ranges from 0 to 1, with lower values indicating pansion period might take 2-5 months.
that the suture region is closer density to the soft palate and
It has been claimed that the slow expansion technique is as-
less calcified, while values close to 1 indicate increased den-
sociated with a more physiologic adjustment to the maxillary
sity and suture fusion.
expansion, producing greater stability and less relapse po-
Protocols of maxillary expansion tential than in rapid expansion procedures. According to a
meta-analysis comparing the effectiveness of RME and slow
1. Conventional Rapid Expansion
palatal expansion, it has been concluded that both methods
Expansion is usually undertaken at a rate of 0.5-1mm (2 to 4 are effective at achieving expansion, with slow palatal expan-
turns) per day. One quarter-turn of the screw yields 0.25 mm sion being more effective overall and more so in the molar
of expansion. 16.6-34.8 pounds (7.54 to 15.8 kg) of pressure region (Zhou et al., 2014). According to a randomised control
is produced by each ¼ turn activation, which depends on the trial, RME can cause significantly more expansion in the area
design of the screw (Zimring and Isaacson, 1965). measured at the pterygoid processes. However, for the rest
of the anatomical areas, it is not superior to the slow palatal
During active expansion, there is an appearance of a transient
expansion (Martina et al., 2012). According to a randomised
upper midline diastema. After active expansion, trans-septal
control trial, RME causes more discomfort and pain than
fibres between the upper central incisors recoil, resulting in
slow maxillary expansion (Martina et al., 2012).
re-approximation of the central incisors. The space created
in the mid-palatal suture region is filled with haemorrhages, 4. Alternate Rapid Maxillary Expansion and Constriction
causing the expansion to be unstable initially. As the resolu- (Alt-RAMEC)
tion of the site occurs, a bony infill takes place into the site,
Liou and Tsai developed a protocol of maxillary protraction
increasing the stability. A period of 3-4 months of retention
in 2005 to loosen the circum-maxillary sutures (Liou and
is required for stability, during which bony infill matures suf-
Tsai, 2005).
ficiently to resist relapse.
Modern designs of RME/ Mini-implant assisted rapid pal-
Teeth movement accompanies active expansion. Conven-
atal expansion (MARPE)
tional expansion protocols include:
MARPE was first proposed by (Lee et al, 2010) in which the
• Timms protocol: For patients up to 15 years of age,
mini-implants can be placed in the maxilla to serve as tem-
1/4 turn in the morning and ¼ turn in the evening.
porary skeletal attachments, and the force is applied directly
In patients over 15 years, Timms recommended a
to the maxillary bone. MARPE can expand the maxilla with
1/4 turn activation 4 times a day.
minimal dental effects, resulting in predominantly skeletal
• Isaacson protocol: In growing young patients, it is changes.
recommended to provide 1/4 turns twice a day for
A randomised control trial comparing tooth and bone borne
4-5 days and later, a ¼ turn per day until the desired
expansion concluded that tooth-borne expansion produced
expansion is achieved. In cases of non-growing adult
more expansion in the premolar area only; for the remain-
patients, it is recommended to provide a ¼ turn in
ing sites of the maxilla, transverse changes are similar in both
the morning, and one in the evening each day for
types of devices (Lagravere et al., 2010).Types of MARPE are
the first two days, then a 1/4 turn per day for the next
(Oh et al., 2019):
5- 7 days and a 1/4 turn every alternate day until the

a) Bone-anchored maxillary expander (BAME) • SARPE is used in cases of low palatal vault (where
palatal tissue can only be minimally stretched).
b) Tooth-bone anchored expander or maxillary skeletal ex-
pansion (MSE): MSE appliances can be used if the permanent Complications during SARPE
posterior teeth are missing or in the case of a compromised
These include:
dentition. It also shortens the treatment time and allows si-
multaneous bonding of the teeth. MSE appliances with a • Infection and pain.
semi-rapid palatal expansion protocol are indicated for grow-
• Hemorrhage (Suri and Taneja, 2008).
ing children as their palatal bone exhibits less resistance than
adults (Oh et al., 2019). • Gingival recession (Carmen et al., 2000).
Surgical maxillary expansion • Increased chances of root resorption (Vardimon et
al., 1993).
These include:
• Injury to the branches of the maxillary nerve (Öz-
1. Surgically assisted RME (SARME or SARPE)
türk et al., 2003).
The surgically assisted rapid palatal expansion (SARME)
• Devitalization of teeth and reduced pulpal blood
concept was introduced in 1938 (Zong et al., 2019). This is
flow.
the main treatment modality for adult patients with maxillary
transverse discrepancy. The main resistance to the maxillary •
Periodontal breakdown (Cureton and Cuenin,
skeletal expansion comes from buttressing the zygomatic and 1999).
sphenoid bones (pterygoid area) at their point of attachment • Extrusion of teeth due to the attachment of the ap-
to the maxilla and from the mid-palatal suture once again pliance (Suri and Taneja, 2008).
fused. With SARPE, these attachment points are surgically
disarticulated to allow expansion to be easily achieved using 2. Multiple piece maxillary osteotomy (MPMO)
a conventional rapid maxillary expansion appliance. MPMO is chosen when along with expansion, the maxilla is
SARPE is a type of distraction osteogenesis, in which the ex- needed to be moved in other directions (for example, impac-
pander is placed with a modified LeFort I osteotomy being tion, down-graft, advancement, setback). The limit of expan-
performed during surgery under general anaesthesia; this sion with MPMO is 8-10mm, due to soft tissue stretch / re-
enables widening of the maxilla against soft tissue resistance sistance. Depending on the height of the palate, MPMO can
only. be considered in cases of a high palatal vault where soft tissue
stretch may be less limiting.
The main advantage of SARPE is the predictable skeletal and
dental changes with a low rate of relapse (5% - 25%) (Baccetti MPMO is chosen in patients with a significant vertical step in
et al., 2001). The main disadvantage of SARPE is the invasive the anterior dentition, where 2 planes are present, which can
nature of the procedure, surgical risks and cost of the sur- be levelled surgically.
gical process. SARPE exhibits some relapse; therefore, over- Research indicates that levelling an anterior step up to 2mm
correction is generally unnecessary. A less invasive SARPE is stable, but research is lacking for leveling anterior occlu-
approach has been proposed involving a zygomatic buttress sal steps greater than 2 mm. Before MPMO, the orthodontist
osteotomy under local anaesthesia. should remove transverse compensations (upright posterior
Indications for SARPE teeth). Minimum segments should be planned during sur-
gery as more segments can alter blood supply and stability.
These include:
Retention and stability secondary to MPMO
• There is a need for expansion after evident mid-pal-
atal suture closure in the adult’ (Alpern and Yurosko, These include:
1987). • A fixed occlusal splint can be placed at the surgery
• Adults with more than 8 mm of transverse discrep- to hold the transverse correction for six weeks post-
ancy (Southard et al., 2019). surgically.
• When the significant maxillary expansion is re- • After removing the splint, a TPA or a heavy overlay
quired. wire is used to hold the transverse correction during
the remaining course of orthodontic treatment.
• SARPE is chosen when significant maxillary inter-
canine width widening is required (e.g. in patients • Alternatively, a rigid stainless steel archwire can be
with significant maxillary arch anterior narrow ta- placed in surgery to stabilise the segments.
pering). • The relapse rate is lower compared with other tech-

niques and varies from 5-25% (Suri and Taneja, arch have also been described.
2008).
Stability and retention of expansion
• Crossbite correction is stable after a follow up of 6.4
It has been documented that up to 40% relapse has been
years, and a decrease in the transverse dimension is
found for all three forms of active expansion (Quad-helix,
most evident during the first 3 years after the treat-
URA expansion plates, or rapid maxillary expansion), and
ment (Magnusson et al., 2008).
there is no difference between them (Herold, 1989). A meta-
Factors & Yardsticks analysis showed only 2.4 mm of expansion remaining after
more than a year, which was no more significant than what
The factors & Yardsticks that determine the type and tech-
has been documented as normal growth. There is insufficient
nique of expansion include:
data to conclude that any useful expansion beyond expected
• Age through normal growth was retained (Schiffman and Tuncay,
2001). Therefore, it is advisable to:
• Aetiology
• Use TPA after SARME
• Buccolingual inclination of the posterior teeth
• Overexpand
• Overbite and overjet
• Stop the cause (habit or mouth breathing)
• Buccal gingivae thickness
• Achieve good buccal segment intercuspation
• The clinical condition of the teeth
• Use fixed retainers or a removable one with a rigid
• Intermolar width measurement
acrylic baseplate
Appliances for unilateral maxillary expansion
• A systematic review reported that at least 6 months
Some patients do have true unilateral crossbites due to unilat- of retention time should be given for all fixed or re-
eral maxillary constriction of the upper arch. The ideal treat- movable appliances to correct a maxillary posterior
ment is to move selected teeth on the constricted side in these crossbite (Costa et al., 2017).
cases.
Anterior crossbites
To a limited extent, this goal can be achieved by using:
The prevalence of anterior crossbites is 0.8% in the perma-
• Different length arms of the W-arch or Quadhelix nent dentition (Brunelle et al., 1996). The primary treatment
• URA with asymmetric sectioning of the acrylic plate modalities of anterior crossbites are:
• An alternative is to use a mandibular lingual arch to • For dentoalveolar or mild skeletal changes, a chin-
stabilise the lower teeth and attach cross elastics to cap or Frankel 3 (Functional) can be used
the maxillary teeth at fault. • Bodily movement using fixed 2x4 appliance
• TAD’s can hold the unaffected side and allow the • Simple tipping movement using URA with posterior
conventional expansion technique to work on the capping, Z spring, double cantilever spring, crossed
affected side. cantilever spring, screw plate.
Treatment of scissor bite An RCT by Wiedel and Bondemark 2014 showed that either
These include: fixed or removable appliance therapy could successfully cor-
rect anterior crossbite with the functional shift in the mixed
• Mild to moderate cases: In a child, a functional ap- dentition from a short-term perspective (Wiedel and Bond-
pliance can be used to correct this relationship by emark, 2015a). Wiedel and Bondemark followed their cases
advancing the mandible forward. This may help cor- and found no difference in terms of stability between fixed
rect the lingual crossbite. In adults, fixed appliances and removable appliances (Wiedel and Bondemark, 2015b).
can be used with cross-elastics and an expanded The same research team undertook another study using the
mandibular archwire, buccal crown torquing of the same sample and found that the cost-effectiveness of a URA
lower posterior teeth or an expanded archwire. is poorer than a fixed appliance (Wiedel et al., 2016). An-
• Severe cases: If there is a skeletal Class II base re- other paper by the same group using the same sample found
lationship, mandibular advancement surgery may that both appliances were low to moderate in terms of pain
help correct the lingual crossbite. Surgical tech- and discomfort (Wiedel and Bondemark, 2016).
niques using distraction osteogenesis for widening Requirement for the successful results using URA
the mandibular arch or constriction of the maxillary
These include:

• Cooperative patient the cleft lip and palate
• Retroclined or uprighted incisors Clinical Features
• Adequate space • Maxillary teeth can be crowded.
• Deep or average overbite • Unilateral or bilateral crossbite with or without
functional jaw displacement.
• Relatively aligned lower labial segment
• Buccally flared upper posterior teeth.
• The lingual cusps of the lower posterior teeth are
tipped inferior to the occlusal plane.
Exam night review • Wide buccal corridors.
Types of maxillary skeletal deficiency • Narrow and high palatal vault (Proffit et al., 2006).
• Relative maxillary deficiency: maxilla = normal, • V or triangular shaped upper arch form.
mandible = comparatively large. • Impacted teeth due to constricted anterior maxilla
• Real maxillary deficiency: maxilla = small. R e l a - (McConnell et al., 1996).
tive transverse discrepancy: In centric relation = Advantages of quad helix
posterior crossbite, but if study models placed in
Class 1 occlusion = no posterior crossbite. • Optimum retention.
• Absolute transverse discrepancy: If study models • No compliance needed.
Class 1 = posterior crossbite still present. • Good range.
Incidence • Can rotate molars.
• Transverse maxillary deficiency 8-22% (Andrade et • Can be used as a habit breaker.
al., 2009).
• Orthopedic effect with differential expansion.
• Posterior crossbite 7.7%,
Disadvantages
• Anterior crossbite 10 % (Allen et al., 2003, O’Brien,
1994). • Little orthopedic change.
• Functional mandibular displacement 80-97% (Thi- • Cause tipping of molars.

lander et al., 1984). • Has a bite opening effect.
Aetiology Expansion Arch (McNally et al., 2005)
• Hereditary • Proposed by Angle 1887, round stainless-steel wire
• Over-retained or an early loss of deciduous teeth (1.135 mm), curved into the shape of a dental arch
• Abnormal tooth anatomy • Inserted into the headgear tubes.
• Premature contact leading to mandibular functional • Positioned over the main appliance
shift Rapid Maxillary Expansion RME
• Arch length discrepancy and crowding • Banded; tooth-borne (HYRAX/ Biedermann and
• Habits such as thumb sucking Isaacson appliances) or tooth and tissue borne (Haas
and Derichsweiler appliances)
• Obstruction of the upper airway due to the enlarged
adenoids • Bonded appliance i.e. mostly tooth-tissue borne.
• Nasal allergies • Hybrid HYRAX, Tooth and bone-borne with TADS.
• Mouth breathing during growing years Proposed indications for RME
• Small maxilla • Crossbite correction (unilateral or bilateral).
• Cleft lip and palate • Correction of a functional mandibular displace-

ment.
• Iatrogenic causes, for example surgical correction of

• Broadening the smile (Moore et al., 2005). Slow Expansion
• In a ‘V-shaped’ arch form due to para-functional • Activation of 1 time per week. No mid-line diaste-
habits. ma. Ratio of skeletal to dental expansion is approx
1:4
• Following Class 2 growth modification to correct
the relative crossbite. Modern designs of RME/ Mini-implant supported palatal
expansion (MARPE)
• To facilitate maxillary protraction with PFM.
• Bone-anchored maxillary expander (BAME)
• Facilitating the eruption of impacted canines or in-
cisors (Baccetti et al., 2011, Pavoni et al., 2013). • Tooth-bone anchored expander (MSE) Hybrid ex-
panders.
• Spontaneous sagittal improvement of Class II (Guest
et al., 2010). Indication of SARME (Southard et al., 2019)
• Preparation for AGB in cleft patients (Shaw and • Adults with more than 5 mm transverse discrepan-
Semb, 1990). cy.
• Space creation: 1mm of inter-molar expansion = • Requirement of soft tissue changes: soft tissues also
0.6mm relief of crowding, and 0.3mm of overjet re- expand with a SARPE (histogenesis).
duction (O’Higgins and Lee, 2000).
• Need for expansion after evident mid-palatal suture
• Expansion to accommodate distalised upper mo- closure.
lars.
• SARME is chosen when only transverse widening
• Improved nasal airflow in patients with nasal ob- is needed, with significant maxillary inter-canine
struction (Almuzian et al., 2016). width widening.
• Improve hearing in patients with conductive hear- • Cases of low palatal vault (where palatal tissue can
ing loss only be minimally stretched).
• Nocturnal enuresis (NE). Complications during SARME
Potential complications of RME • Significant hemorrhage (Suri and Taneja, 2008)
• Pain and soreness. • Gingival recession (Carmen et al., 2000)
• Periodontal damage. • Increased chances of root resorption (Vardimon et
al., 1993)
• Root resorption (OIRR).
• Injury to the branches of the maxillary nerve (Öz-
• Vertical dimension changes.
türk et al., 2003)
• Occurrence of scissor bite in case of over-correction.
• Infection
Protocols of maxillary expansion
• Pain
Conventional Rapid Expansion
• Devitalization of teeth and reduced pulpal blood
• Activate 2-4 times per day = 0.5-1mm per day (0.25 flow
per activation)
• Periodontal breakdown (Cureton and Cuenin, 1999)
• During RME →transient midline diastema. Sepa-
• Extrusion of teeth due to the attachment of the ap-
rates in a pyramidal manner. 3-4 months is required
pliance (Suri and Taneja, 2008)
for retention and stability.
Semi-rapid expansion
• Activated 2 times per day for 5 – 6 days followed by
3 times per week.
Hybrid expansion
• Activation tapers, day 1 = 4 times activation, day 2 =
2 times activation, day 3 = 1 activation. Followed by
2 activations per week (Perillo et al, 2014).

References 2000. Periodontal evaluation in patients undergoing maxillary
expansion. The Journal of craniofacial surgery, 11, 491-494.
AGOSTINO, P., UGOLINI, A., SIGNORI, A., SILVESTRINI-
BIAVATI, A., HARRISON, J. E. & RILEY, P. 2014. Orthodontic CHUNG, C.-H. 2019. Diagnosis of transverse problems. Seminars
treatment for posterior crossbites. Cochrane Database Syst Rev, in Orthodontics, 25, 16-23.
Cd000979.
COBOURNE, M. T., FLEMING, P. S., DIBIASE, A. T. & AHMAD,
ALLEN, D., REBELLATO, J., SHEATS, R. & CERON, A. M. 2003. S. 2012. Clinical cases in orthodontics, John Wiley & Sons.
Skeletal and Dental Contributions to Posterior Crossbites. The
COSTA, J. G., GALINDO, T. M., MATTOS, C. T. & CURY-SARA-
MAGO, A. A. 2017. Retention period after treatment of posterior
ALMUZIAN, M., SHORT, L., ISHERWOOD, G., AL-MUZIAN, L. crossbite with maxillary expansion: a systematic review. Dental
& MCDONALD, J. 2016. Rapid maxillary expansion: a review of Press J Orthod, 22, 35-44.
appliance designs, biomechanics and clinical aspects. Orthodontic
CURETON, S. L. & CUENIN, M. 1999. Surgically assisted rapid
Update, 9, 90-95.
palatal expansion: orthodontic preparation for clinical success.
ALPERN, M. C. & YUROSKO, J. J. 1987. Rapid palatal expansion American journal of orthodontics and dentofacial orthopedics,
in adults with and without surgery. Angle Orthod, 57, 245-63. 116, 46-59.
ANDRADE, A. S., GAMEIRO, G. H., DEROSSI, M. & GAVIÃO, ENGLISH, J. D., AKYALCIN, S., PELTOMAKI, T. & LITSCHEL,
M. B. D. 2009. Posterior Crossbite and Functional Changes. The K. 2014. Mosby’s orthodontic review, Elsevier Health Sciences.
ERICSON S & KUROL J 1987, R. A. O. E. M. C., AJODO, 91 ;483-
ANGELIERI, F., CEVIDANES, L. H., FRANCHI, L., GON- 492.
CALVES, J. R., BENAVIDES, E. & MCNAMARA, J. A., JR. 2013.
FAGUNDES, N. C. F., RABELLO, N. M., MAIA, L. C., NORMAN-
Midpalatal suture maturation: classification method for individual
DO, D. & MELLO, K. 2017. Can rapid maxillary expansion cause
assessment before rapid maxillary expansion. Am J Orthod Dento-
auditory improvement in children and adolescents with hearing
loss? A systematic review. Angle Orthod, 87, 886-896.
BACCETTI, T., FRANCHI, L., CAMERON, C. G. & MCNAMA-
FORST, D., NIJJAR, S., KHALED, Y., LAGRAVERE, M. &
RA, J. A., JR. 2001. Treatment timing for rapid maxillary expan-
FLORES-MIR, C. 2014. Radiographic assessment of external root
sion. Angle Orthod, 71, 343-50.
resorption associated with jackscrew-based maxillary expansion
BACCETTI, T., SIGLER, L. M. & MCNAMARA, J. A., JR. 2011. An therapies: a systematic review. Eur J Orthod, 36, 576-85.
RCT on treatment of palatally displaced canines with RME and/or
GARINO, F. & GARINO, G. 2002. Comparison of dental arch
a transpalatal arch. Eur J Orthod, 33, 601-7.
measurements between stone and digital casts. World J Orthod, 3,
BARATIERI, C., ALVES, M., JR., DE SOUZA, M. M., DE SOUZA 250-4.
ARAUJO, M. T. & MAIA, L. C. 2011. Does rapid maxillary expan-
GILL, D., NAINI, F., MCNALLY, M. & JONES, A. 2004. The Man-
sion have long-term effects on airway dimensions and breathing?
agement of Transverse Maxillary Deficiency. Dental Update, 31,
516-523.
BISHARA, S. E., ORTHO, D., JAKOBSEN, J. R., TREDER, J. &
GORDON, J. M., ROSENBLATT, M., WITMANS, M., CAREY, J.
NOWAK, A. 1997. Arch width changes from 6 weeks to 45 years of
P., HEO, G., MAJOR, P. W. & FLORES-MIR, C. 2009. Rapid palatal
age. American Journal of Orthodontics and Dentofacial Orthope-
expansion effects on nasal airway dimensions as measured by
dics, 111, 401-409.
acoustic rhinometry: a systematic review. The Angle Orthodontist,
BISHARA, S. E. & STALEY, R. N. 1987. Maxillary expansion: clini- 79, 1000-1007.
cal implications. American journal of orthodontics and dentofacial
GRAMMATOPOULOS, E., WHITE, A. P. & DHOPATKAR,
orthopedics, 91, 3-14.
A. 2012. Effects of playing a wind instrument on the occlusion.
BJÖRK, A. & SKIELLER, V. 1974. Growth in Width of the Maxilla American Journal of Orthodontics and Dentofacial Orthopedics,
Studied by the Implant Method. Scandinavian Journal of Plastic 141, 138-145.
and Reconstructive Surgery, 8, 26-33.
GRUNHEID, T., LARSON, C. E. & LARSON, B. E. 2017. Midpala-
BRUNELLE, J. A., BHAT, M. & LIPTON, J. A. 1996. Prevalence and tal suture density ratio: A novel predictor of skeletal response to
distribution of selected occlusal characteristics in the US popula- rapid maxillary expansion. Am J Orthod Dentofacial Orthop, 151,
tion, 1988-1991. J Dent Res, 75 Spec No, 706-13. 267-276.
BSI 1983. British standard glossary of dental terms, British Stan- GUEST, S. S., MCNAMARA, J. A., JR., BACCETTI, T. & FRAN-
dards Institution. CHI, L. 2010. Improving Class II malocclusion as a side-effect
of rapid maxillary expansion: a prospective clinical study. Am J
BUCK, L. M., DALCI, O., DARENDELILER, M. A., PAPAGEOR-
GIOU, S. N. & PAPADOPOULOU, A. K. 2017. Volumetric upper
airway changes after rapid maxillary expansion: a systematic review HAAS, A. J. 1961. Rapid Expansion Of The Maxillary Dental Arch
and meta-analysis. Eur J Orthod, 39, 463-473. And Nasal Cavity By Opening The Midpalatal Suture. The Angle
CARMEN, M., MARCELLA, P., GIUSEPPE, C. & ROBERTO, A.

HAAS, A. J. 1965. The Treatment Of Maxillary Deficiency By MCNAMARA, J. A., BRUDON, W. L. & KOKICH, V. G. 2001.
Opening The Midpalatal Suture. The Angle Orthodontist, 35, 200- Orthodontics and dentofacial orthopedics, Needham Press.
217.
MCNAMARAA, J. A. 2000. Maxillary transverse deficiency.
HALICIOGLU, K., KIKI, A. & YAVUZ, I. 2012. Subjective symp- American journal of orthodontics and dentofacial orthopedics,
toms of RME patients treated with three different screw activation 117, 567-570.
protocols: a randomised clinical trial. Aust Orthod J, 28, 225-31.
MELSEN, B. 1975. Palatal growth studied on human autopsy mate-
HEROLD, J. S. 1989. Maxillary expansion: a retrospective study rial. A histologic microradiographic study. Am J Orthod, 68, 42-54.
of three methods of expansion and their long-term sequelae. Br J
MOLEN, A. D. 2010. Considerations in the use of cone-beam com-
Orthod, 16, 195-200.
puted tomography for buccal bone measurements. Am J Orthod
ISAACSON, J. R., ISAACSON, R. J., SPEIDEL, T. M. & WORMS, F. Dentofacial Orthop, 137, S130-5.
W. 1971. Extreme variation in vertical facial growth and associated
MOORE, T., SOUTHARD, K. A., CASKO, J. S., QIAN, F. &
variation in skeletal and dental relations. Angle Orthod, 41, 219-29.
SOUTHARD, T. E. 2005. Buccal corridors and smile esthetics. Am
IŞERI, H. & OZSOY, S. 2004. Semirapid maxillary expansion--a J Orthod Dentofacial Orthop, 127, 208-13; quiz 261.
study of long-term transverse effects in older adolescents and
MOYERS, R. E. 1976. Standards of human occlusal development.
adults. Angle Orthod, 74, 71-8.
NANDA, R. 2005. Biomechanics and esthetic strategies in clinical
JACOBSON, A. 1991. Functional appliances in orthodontic treat-
orthodontics, Elsevier Health Sciences.
ment: An atlas of clinical prescription and laboratory construction
Harry S. Orton Quintessence Publishing Co., 103 (8 112× 12 ″) O’BRIEN, M. 1994. Children’s dental health in the United Kingdom
pages. Mosby. 1993, HMSO.
KUTIN, G. & HAWES, R. R. 1969. Posterior crossbites in the de- O’HIGGINS, E. A. & LEE, R. T. 2000. How much space is created
ciduous and mixed dentitions. Am J Orthod, 56, 491-504. from expansion or premolar extraction? J Orthod, 27, 11-3.
LAGRAVERE, M. O., CAREY, J., HEO, G., TOOGOOD, R. W. ODENRICK, L., KARLANDER, O. D., EVA LILJA, PIERCE, O. D.,
& MAJOR, P. W. 2010. Transverse, vertical, and anteroposterior ANGELA, FRACDS, O. D. & KRETSCHMAR, U. 1991. Surface
changes from bone-anchored maxillary expansion vs traditional resorption following two forms of rapid maxillary expansion. The
rapid maxillary expansion: a randomised clinical trial. Am J Or- European Journal of Orthodontics, 13, 264-270.
thod Dentofacial Orthop, 137, 304.e1-12; discussion 304-5.
OH, H., PARK, J. & LAGRAVERE-VICH, M. O. 2019. Comparison
LIOU, E. J. & TSAI, W. C. 2005. A new protocol for maxillary of traditional RPE with two types of micro-implant assisted RPE:
protraction in cleft patients: repetitive weekly protocol of alternate CBCT study. Seminars in Orthodontics, 25, 60-68.
rapid maxillary expansions and constrictions. Cleft Palate Cranio-
ÖZTÜRK, M., DORUK, C., ÖZEÇ, İ., POLAT, S., BABACAN, H.
fac J, 42, 121-7.
& BIÇAKCI, A. A. 2003. Pulpal blood flow: effects of corticotomy
LO GIUDICE, A., BARBATO, E., COSENTINO, L., FERRARO, C. and midline osteotomy in surgically assisted rapid palatal expan-
M. & LEONARDI, R. 2018. Alveolar bone changes after rapid max- sion. Journal of Cranio-Maxillofacial Surgery, 31, 97-100.
illary expansion with tooth-born appliances: a systematic review.
PALLA, A. & N, D. K. 2018. Orthodontics, Posterior Crossbite.
Eur J Orthod, 40, 296-303.
StatPearls. Treasure Island (FL): StatPearls Publishing
LUX, C. J., CONRADT, C., BURDEN, D. & KOMPOSCH, G. 2003.
StatPearls Publishing LLC.
Dental arch widths and mandibular-maxillary base widths in Class
II malocclusions between early mixed and permanent dentitions. PATCAS, R., MULLER, L., ULLRICH, O. & PELTOMAKI, T. 2012.
The Angle Orthodontist, 73, 674-685. Accuracy of cone-beam computed tomography at different resolu-
tions assessed on the bony covering of the mandibular anterior
MAGNUSSON, A., BJERKLIN, K., NILSSON, P. & MARCUSSON,
teeth. Am J Orthod Dentofacial Orthop, 141, 41-50.
A. 2008. Surgically assisted rapid maxillary expansion: long-term
stability. The European Journal of Orthodontics, 31, 142-149. PAVONI, C., FRANCHI, L., LAGANA, G. & COZZA, P. 2013.
Radiographic assessment of maxillary incisor position after rapid
MARTINA, R., CIOFFI, I., FARELLA, M., LEONE, P., MANZO, P.,
maxillary expansion in children with clinical signs of eruption
MATARESE, G., PORTELLI, M., NUCERA, R. & CORDASCO, G.
disorder. J Orofac Orthop, 74, 468-79.
2012. Transverse changes determined by rapid and slow maxil-
lary expansion--a low-dose CT-based randomised controlled trial. PIERO, A. 2006. Interceptive orthodontics—the need for early di-
Orthod Craniofac Res, 15, 159-68. agnosis and treatment of posterior crossbites. Med Oral Patol Oral
Cir Bucal, 11, 210-214.
MCCONNELL, T. L., HOFFMAN, D. L., FORBES, D. P., JANZEN,
E. K. & WEINTRAUB, N. H. 1996. Maxillary canine impaction PRAKASH, P. & DURGESH, B. 2010. Anterior crossbite correc-
in patients with transverse maxillary deficiency. ASDC journal of tion in early mixed dentition period using Catlan’s appliance: a case
dentistry for children, 63, 190-195. report. ISRN dentistry, 2011.
MCNALLY, M., SPARY, D. & ROCK, W. 2005. A randomised con- PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
trolled trial comparing the quadhelix and the expansion arch for temporary orthodontics, Elsevier Health Sciences.
the correction of crossbite. Journal of orthodontics, 32, 29-35.

SCHIFFMAN, P. H. & TUNCAY, O. C. 2001. Maxillary expansion: of RCTs in the last 12 years. Eur J Orthod, 35, 29-37.
a meta analysis. Clin Orthod Res, 4, 86-96.
SHAW, W. & SEMB, G. 1990. Current approaches to the orthodon-
tic management of cleft lip and palate. Journal of the Royal Society
of Medicine, 83, 30-33.
SOUTHARD, T. E., MARSHALL, S. D., ALLAREDDY, V. & SHIN,
K. 2019. Adult transverse diagnosis and treatment: A case-based
review. Seminars in Orthodontics, 25, 69-108.
SURI, L. & TANEJA, P. 2008. Surgically assisted rapid palatal ex-
pansion: a literature review. American journal of orthodontics and
dentofacial orthopedics, 133, 290-302.
THILANDER, B., WAHLUND, S. & LENNARTSSON, B. 1984.
The effect of early interceptive treatment in children with posterior
crossbite. The European Journal of Orthodontics, 6, 25-34.
VALENCIA, R. M. 2007. Treatment of unilateral buccal cross-
bites in the primary, early mixed, and permanent dentitions: case
reports. J Clin Pediatr Dent, 31, 214-8.
VARDIMON, A., GRABER, T. & PITARU, S. 1993. Repair process
of external root resorption subsequent to palatal expansion treat-
ment. American Journal of Orthodontics and Dentofacial Orthope-
dics, 103, 120-130.
WEISSHEIMER, A., DE MENEZES, L. M., MEZOMO, M., DIAS,
D. M., DE LIMA, E. M. S. & RIZZATTO, S. M. D. 2011. Immediate
effects of rapid maxillary expansion with Haas-type and hyrax-type
expanders: a randomised clinical trial. American journal of ortho-
dontics and dentofacial orthopedics, 140, 366-376.
WERTZ, R. A. 1970. Skeletal and dental changes accompanying
rapid midpalatal suture opening. American journal of orthodon-
tics, 58, 41-66.
WIEDEL, A. P. & BONDEMARK, L. 2015a. Fixed versus remov-
able orthodontic appliances to correct anterior crossbite in the
mixed dentition--a randomised controlled trial. Eur J Orthod, 37,
123-7.
WIEDEL, A. P. & BONDEMARK, L. 2015b. Stability of anterior
crossbite correction: a randomised controlled trial with a 2-year
follow-up. Angle Orthod, 85, 189-95.
WIEDEL, A. P. & BONDEMARK, L. 2016. A randomised con-
trolled trial of self-perceived pain, discomfort, and impairment of
jaw function in children undergoing orthodontic treatment with
fixed or removable appliances. Angle Orthod, 86, 324-30.
WIEDEL, A. P., NORLUND, A., PETRÉN, S. & BONDEMARK, L.
2016. A cost minimisation analysis of early correction of anterior
crossbite-a randomised controlled trial. Eur J Orthod, 38, 140-5.
ZHOU, Y., LONG, H., YE, N., XUE, J., YANG, X., LIAO, L. & LAI,
W. 2014. The effectiveness of non-surgical maxillary expansion: a
meta-analysis. Eur J Orthod, 36, 233-42.
ZONG, C., TANG, B., HUA, F., HE, H. & NGAN, P. 2019. Skeletal
and dentoalveolar changes in the transverse dimension using
microimplant-assisted rapid palatal expansion (MARPE) appli-
ances. Seminars in Orthodontics, 25, 46-59.
ZUCCATI, G., CASCI, S., DOLDO, T. & CLAUSER, C. 2013.
Expansion of maxillary arches with crossbite: a systematic review

Dental & Skeletal
16
Asymmetries
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam
In this Chapter
1. Prevalence of dental & skeletal asymmetries 15. Hemifacial atrophy (Parry-Romberg syn
2. Aetiology of dental & skeletal asymmetries drome)
3. Classification of dental & skeletal asymme 16. Asymmetric mandibular excess
tries 17. Management of asymmetric mandibular
4. Traumatic asymmetry excess
5. Management of condylar fractures in chil 18. Mandibular displacements on closure
dren 19. Dental asymmetries
6. Hemifacial microsomia (HFM) 20. Causes of dental midline asymmetry
7. Clinical features of HFM 21. Class II subdivision
8. Types of HFM 22. Class III subdivisions
9. Classification of HFM 23. Examination of asymmetry
10. Juvenile Rheumatoid Arthritis (JRA) 24. Management of functional asymmetry
11. Treatment of Juvenile Rheumatoid Arthritis 25. Management of skeletal asymmetry
12. Idiopathic condylar resorption (ICR) 26. EXAM NIGHT REVIEW
13. Torticollis (Wry Neck)
14. Hemifacial hypertrophy
A symmetry is defined as an absence of conformity in size,
sure and moulding, habits e.g. thumb sucking and
condylar hypoplasia/ hyperplasia
shape and relative position of parts on either side of a divid-
ing line or median plane or about a centre or an axis. Facial • Developmental factors (Chia et al., 2008) such as
asymmetry is defined as an imbalance between the left and Hemimandibular elongation/ hyperplasia, Condy-
right sides of the face (Chia et al., 2008). At the same time, lar hypo- or hyperplasia, Hemifacial macrosomia,
dental asymmetry represents dental midline discrepancy Hemifacial hypertrophy, Hemifacial atrophy (Parry-
from the facial midline. Romberg syndrome), Achondroplasia, Torticollis,
Unilateral cleft lip and palate and Childhood frac-
Prevalence of dental & skeletal asymmetries tures of the jaw.
Amongst orthodontic patients, 12% had facial asymme- • Pathological factors such as Tumors of the head and
tries and 21% dental asymmetries. The most common neck region ( Ameloblastoma arising in body and ra-
asymmetry was mandibular midline deviation (62%), mus of mandible, tumours of condylar head includ-
followed by non-coincident dental midlines (46%), max- ing osteoma, osteochondroma, chondrosarcoma),
illary midline deviation from the facial midline (39%), cysts (Dentigerous cysts, keratocysts, lymphoepi-
molar classification asymmetry (22%), maxillary occlu- thelial cysts), Fibrous dysplasia, Infection (Dento-
sal asymmetry (20%), mandibular occlusal asymmetry alveolar abscesses, acute parotitis), Decreased tonic
(18%), facial asymmetry (6%), chin deviation (4%), and muscular activity (muscle weakness syndromes such
nose deviation (3%) (Sheats, 1998). as cerebral palsy, muscular dystrophy), Muscular
Most people have an asymmetry in the face and dentition, atrophy due to impaired motor nerves and condy-
but it is usually sub-clinical (Shah and Joshi, 1978) with lar resorption due to juvenile rheumatoid arthritis,
no gender difference was noted (Melnik, 1991); however, post-steroid therapy and following orthognathic
the right side of the face is commonly larger than the left surgery.
side (Peck et al., 1991). The clinical threshold for skeletal • Traumatic factors including condylar fractures and
asymmetry was close to 5mm (McAvinchey et al., 2014). subsequent ankylosis, which results in an asymme-
Regarding dental asymmetry, 56% of laypersons and 83% try of the jaw (Proffit et al., 1980).
of orthodontists can recognize a 2mm dental asymme-
try (Burden 1999). A systematic review found up to 2.2 • Functional factors include the functional shift from
mm of midline deviation is considered acceptable (Jan- centric occlusion to centric relation (CO-CR), lead-
son 2011). A cant of 10º or greater was considered unac- ing to mandibular displacement and asymmetry in
ceptable by 70% of orthodontists and 40% of laypeople growth. This is primarily due to constricted maxilla
(Thomas 2008). or premature contacts.
Growing children between the age of 7 to 16 may mani- • Idiopathic and iatrogenic factors such as idiopathic
fest mandibular asymmetry, and history of trauma was condylar resorption and improper orthodontic or
found in only 14% of patients with asymmetry. The dis- orthognathic planning and treatment
crepancy can appear to reduce for some patients due to • Local factors such as retained/ missing teeth or pre-
bony remodelling and soft tissue camouflage (Melnik, mature loss of primary teeth
1992, Liukkonen et al., 2005). 26% of orthognathic pa-
Classification of dental & skeletal asymmetries
tients present with facial asymmetry (Proffit, 1996),
mainly class III (40%) followed by Class II orthognathic These include:
cases (25%). The mandible and the dentoalveolar region
• Skeletal asymmetry mainly affects maxillary, man-
exhibited the greatest degree of asymmetry. This is be-
dibular basal bone or their combination (Bishara et
cause the growth of the mandible exhibits the longest pe-
al., 1994).
riod of growth and 90% of mandibular deviations are to
the left. Chin deviation affects 80% of orthognathic cases, • Dental asymmetry due to retained or missing teeth
and overall, 60% had an asymmetry in the lower face. The or habits e.g. Thumb-sucking
midface (primarily the nose) also was affected in about
• Muscular asymmetry, including any craniofacial
30% of the asymmetric patients.
muscle hypertrophy or atrophy such as cerebral pal-
sy.
Aetiology of dental & skeletal asymmetries • Functional asymmetry secondary to TMJ dysfunc-
tion or a CO-CR shift.
These include:
Overview of different types of asymmetry
• Environmental factors such as intra-uterine pres-
158 Asymmetries
Traumatic asymmetry • Severely malformed or absent pinna of the ear.
Condylar fractures are mostly unilateral, with 75% of chil- • Periauricular skin tags.
dren having normal mandibular growth without the devel-
• Variable degrees of nerve palsy (due to the associa-
opment of an asymmetry. Moreover, most condylar fractures
tion of specific cranial nerves with branchial arches)
remain undiagnosed (Proffit et al., 1980).
• Reduction in size or flattening of facial bones due to
Management of condylar fractures in children
the reduced size of the masticatory muscles.
These include:
• Mandibular asymmetry of varying severity (unilat-
• Immobilization followed by early mobilization. eral aplasia or hypoplasia of the mandibular ramus
and condyle).
• Hybrid functional appliance: The aim of growth
modification in asymmetry cases is to achieve more • Cleft lip and palate, palatal and tongue muscle hy-
growth on one side than the other (Turvey et al., poplasia and velopharyngeal insufficiency occur less
2004). Hybrid functional appliances consist of sev- commonly.
eral components to achieve selective dento-alveolar
• Unilateral crossbite on the affected side and canting
eruption, mandibular repositioning and optimal
of the occlusal plane.
linguofacial muscle balance, which favour growth to
compensate for asymmetric mandibular deficiencies • Disturbed tooth development on the affected side
(Vig et al., 1986). A wax bite is taken to achieve a (hypodontia is 5 times more common compared
symmetric jaw relationship in three planes of space. with the average population) (Monahan et al., 2001).
A greater vertical opening is registered on the af-
Types of HFM
fected side; with this, downward torque of the ramus
improve the vertical defect. The unaffected side fea- These include:
tures a posterior bite plane to inhibit tooth eruption • Type I Hypoplastic temporomandibular joint
and allow the deficient side to allow teeth eruption.
A lingual shield is incorporated on the affected side • Type II—hypoplastic and abnormal shape of the
to prevent the tongue from interfering with tooth mandibular ramus, condyle, and temporomandibu-
eruption. A buccal shield is incorporated on the af- lar joint
fected side to achieve transverse expansion. • Type III Absence of the mandibular ramus
• Suppose the translation of the condyle is severely re- • Type IV Mandibular body hypoplasia
stricted due to post-traumatic scarring. In that case,
pre-functional surgical intervention is indicated to Classification of HFM
remove restrictions on growth and allow translation Kaban’s modified classification (Madrid et al., 2010) clas-
of the condyle, followed by hybrid functional appli- sified HFM according to the extent of malformation and
ance therapy and regular jaw exercises. managemet (Table 1).
Hemifacial microsomia (HFM) Juvenile Rheumatoid Arthritis (JRA)
This is a congenital disorder associated with unilateral devel- It is an inflammatory disease process that affects bone and
opmental defects in the orofacial region. The proposed aeti- cartilage. In JRA with one to three affected joints, the TMJ is
ologies for HFM include: involved in 33% of cases, while in JRA with greater than four
• Defect in proliferation and migration of neural crest affected joints, the TMJ is involved in 80% of cases (Ince et al.,
cells resulting in defects of 1st and 2nd arch struc- 2000). Progressive destruction of condyles results in shorten-
tures. ing of the ramus and downward and backward rotation of the
chin, which leads to chin deficiency and anterior open bite.
• Hemorrhage of the stapedial artery (Poswillo, 1973). Condylar resorption may occur faster on one side than the
• Goosecoid (Gsc) - potential candidate gene for other, resulting in mandibular asymmetry in 2/3rds – 3/4ths
Hemifacial microsomia (Kelberman et al., 2001). of affected children.
Clinical features of HFM
These include:
• Narrowed palpebral fissures.
• Unilateral epibulbar dermoids.
Asymmetries 159
Features Treatment approach
Grade 1 Soft tissues and mandible present, Functional appliance therapy is attempted before sur-
gery.
hypoplastic temporomandibular joint
Grade 2a Hypoplastic and abnormal shape of the man- Same approach as for grade 1
dibular ramus, condyle, and temporomandibular
Early surgical intervention to lengthen the ramus
joint, and effects on muscles of mastication
through distraction + / - functional appliance therapy.
Orthognathic surgery as an adult.
Grade 2b Mandibular ramus is hypoplastic and markedly Condyle is considered to be non-functional. Early sur-
abnormal in form and location, being medial gery involving costochondral graft.
and anterior.
Total joint replacement as an adult.
Grade 3 Complete absence of the condyle and ramus as Same approach as for the severe grade 2
well as severe soft tissue defects
Table 1: Kaban’s modified classification of HFM
Hemifacial hypertrophy
Treatment of Juvenile Rheumatoid Arthritis
It is hypertrophy of one side of the face, and it is mainly due
These include: to the asymmetric distribution of neural crest cells. It is char-
• Methotrexate is the most effective agent for retard- acterized by overgrowth in the craniofacial structures (in-
ing disease progression. cluding soft and hard tissues). Occlusion is also likely to be
affected.
• Functional appliances and any surgical procedures
which affect the TMJ (e.g. orthognathic surgery or
distraction osteogenesis) should be avoided. The Hemifacial atrophy (Parry-Romberg syndrome)
application of force on the TMJ accelerates disease
processes and condylar destruction. It is progressive atrophy of soft tissues and underlying bones
on one side of the face. More common on the left side and
• Total TMJ replacement in severe cases. in females. Clinical features of Parry-Romberg syndrome are:
• Surgical maxillary impaction might be considered • Atrophic facial changes include tissues around the
in adolescents as this results in upward and forward nose and nasolabial folds, which later progress to the
rotation of the mandible, improving open bite and angle of the mouth, eyes, ears and neck (follows the
chin deficiency. Relapse is expected as a shortening distribution of the trigeminal nerve).
of ramus continues (disease progression at the TMJ).
• Hyperpigmentation of the skin.
• Augmentation genioplasty improves facial appear-
ance and does not add extra load on the TMJ. • Seizures
Idiopathic condylar resorption (ICR) • Facial pain
The predisposing factors for ICR are preoperative temporo- • Muscle and facial bone atrophy lead to mandibular
mandibular joint dysfunction (Hwang et al., 2004), young asymmetry.
and female patients (due to hormonal factors) and high man- •
dibular plane angle with mandibular retrusion.
Asymmetric mandibular excess
Torticollis (Wry Neck)
This type of asymmetry was previously called condylar hy-
It is a muscular disorder that affects flexion, extension, or perplasia. It is due to excessive unilateral growth of the man-
twisting of the neck muscles beyond their normal position. dible, which may affect the body, ramus and condyle. This
Mandibular asymmetry arises due to twisting of the head due spectrum of asymmetry includes Hemimandibular elonga-
to excessive muscular contraction (especially sternocleido- tion, Hemimandibular hyperplasia and hybrid type elonga-
mastoid muscle). In children, it is due to congenital factors tion (Obwegeser and Makek, 1986) (Table 2 and 3). The exact
such as increased intrauterine pressure during pregnancy or aetiology of this malformation is unknown, but it may occur
pressure during birth. In adults, it can be due to infection, due to the escape of growing tissues on one side from normal
tumours or trauma. Treatment of Torticollis includes surgical regulatory control (Eslami et al., 2003). Affected individuals
detachment of contracted muscles at an early age to release are metabolically normal with normal hard and soft tissue as
any growth restriction on the affected side (Ferguson, 1993).
160 Asymmetries
Table 2: Comparison between Hemimandibular Elongation & Hemimandibular Hyperplasia
Hemimandibular elongation Hemimandibular hyperplasia
Unilateral horizontal enlargement of mandible Unilateral three-dimensional enlargement of mandible terminat-
ing at symphysis of the affected side
Both horizontal and vertical components contribute to the abnor-
mal growth pattern.
Horizontal displacement of chin point to the unaffected Chin position mostly undisturbed
side
Dental midline usually displaced to the unaffected side Dental midlines usually coincident
Mandibular dental midline may coincide with chin point Dental centerline and chin are often undisturbed
but does not coincide with midfacial line
Mandibular rami lie at the same level bilaterally Increased ramal length and hyperplasia of the lower border of the
mandible on affected side
Body of the mandible displaced inferiorly and rotated medially
Normal alveolar bone height above inferior alveolar canal Increased alveolar bone height above inferior alveolar canal of
of affected side affected side
No compensatory transverse canting of the maxillary oc- Transverse canting of the maxillary occlusal plane due to over-
clusal plane eruption of maxillary dentition on affected side to compensate for
excessive mandibular overgrowth
Occlusal plane remains level No lateral open bite of buccal
segment
A unilateral lateral open bite on affected side if dental eruption
cannot keep pace with excessive vertical mandibular growth,
especially if tongue becomes interposed
Crossbite on unaffected side A unilateral lateral open bite on affected side if dental eruption
cannot keep pace with excessive vertical mandibular growth
Scissor bite on affected side
especially if tongue becomes interposed
Radiographic findings: Radiographic findings:
Elongation of the affected side of the mandibular body Increased vertical length of ascending ramus
Enlargement of condyle
Elongation and thickening of condylar neck
Rounded angle of mandible
Downward bowing of lower border of mandible on affected side
Increased height of mandibular body
Increased distance between molar roots and mandibular canal
Normal height seen on unaffected side
Excessive growth demarcated by abruptly stopping at midline of
symphysis
confirmed by histologic diagnosis. Females constitute 85% of Management of asymmetric mandibular excess
affected cases; the age of onset of this excessive growth dis-
order is during the mid to late teenage years, as mandibular In cases of progressive deformity, surgical intervention of the
growth progresses and becomes noticeable after the adoles- overgrown condyle is indicated even in young patients. Surgi-
cent growth spurt. It may be self-limiting or a progressive cal options are:
condition. • Excision of bone at the head of the condyle followed by
Asymmetries 161
Type I Broad proliferative zone cant of the occlusal plane.
Increased thickness of hyaline carti- • Pitch: Rotation of the dentition about a coronal axis.
lage Causes of dental midline asymmetry
Cartilage islands within the bone These include:
Type II Patchy distribution • Early loss of teeth
Reduced cartilage islands • Congenitally missing teeth
Type III Distortion of condyle
• Impacted teeth
Irregular hyaline cartilage masses ex-
• Single or multiple tooth crossbite causing functional
tend into cancellous bone of the con-
mandibular shift on closure
dyle or superficial articular layer
Type IV Condyle appears burned-out • Inappropriate extraction in case of crowding
Subchondral bone plate covered by fi- Class II subdivision

brocartilage Subdivision refers to the Class II side. It is mostly due to distal
Proliferative layer of hyaline cartilage positioning of the lower first molar on the Class 2 side but
absent rarely due to the upper molar occupying a more mesial posi-
tion (Janson et al., 2001) (Alavi et al., 1988) (Rose et al., 1994).
Table 3: Histological classification of mandibular condylar 60% of Class II subdivision asymmetries were due to a 2 mm
hyperplasia (Slootweg and Müller, 1986) retrusion of the mandible on the Class II side, according to a
• recontouring or repositioning of the bony stump CBCT study (Sanders et al., 2010). Class II subdivisions and
into glenoid fossa their management is provided in table 4 (Janson et al., 2007).
• Removal of the condyle and condylar process fol- Class III subdivisions
lowed by reconstruction of the TMJ, either with a Subdivision refers to the Class III side. The treatment op-
costochondral junction transplant or with a free tions are:
graft (Boyne, 1989).
• In cases of crowding with a deviated maxillary mid-
• For adults, total joint replacement of the TMJ can be line, it is advisable to extract two lower premolars
performed. and a single upper premolar on the Class III side.
• If excessive growth stops spontaneously and the • In cases of deviation of the mandibular midline only,
condition stabilizes, jaw surgery is delayed until after it is advisable to extract only one lower premolar on
the adolescent growth spurt without involvement of the Class III side. The benefit of extracting a single
the TMJ. lower tooth instead of two is the better control of the
Mandibular displacements on closure lower midline and reduced requirement for asym-
metric elastics.
It is mainly due to transverse maxillary constriction or pre-
mature contacts. Mandibular asymmetry may develop due to
the shortening of the ramal height due to growth restriction Examination of asymmetry
on the side of the crossbite (Schmid et al., 1991).
These include:
Dental asymmetries
• Extraoral soft tissue examination includes assessing
It is considered the most challenging dental malocclusion deviations of the dorsum and tip of the nose, phil-
to correct (along with overjet) (Kokich, 1993); hence, it was trum of upper lip and midpoint of the chin about the
given a weighting of 4 in the Peer Assessment Rating (PAR) facial midline. It also contains extraoral examination
Index (DeGuzman et al., 1995). Dental asymmetries can oc- in which mandibular asymmetry is assessed from a
cur in three planes of space. frontal view, superior view (bird’s eye view) or infe-
• Yaw: Discrepancy of the dentition about a vertical rior view (worm’s eye view) to reveal the extent of
axis resulting in a dental midline asymmetry (Ack- the deviation.
erman et al., 2007). • Intraoral clinical examinations include assessing the
• Roll: Discrepancy in the transverse plane about a dental midlines relative to each other and the facial
sagittal axis is termed roll deformity and results in midline and assessing the mandibular displacement
162 Asymmetries
Table 4: Class II subdivisions and their management
Types of Class 2 Features Treatment

subdivision
Class 2, type I Is found in about 60% of Treatment is aimed at mandibular arch
subdivision cases.
• Non-extraction approach includes asymmetric class 2/ class 3 elastics
Maxillary dental midline or heavy anterior diagonal elastics supported by class 2 elastics.
coincides with the facial
• Extraction of three units (two upper units and one lower unit on the
midline but mandibular
unaffected side).
midline is deviated
• Newer treatment approach includes the use of TADs or class 2 correc-
tors for protraction of the mandibular arch on Class 2 side.
Class 2, type II Is found in about 20% of Treatment is aimed at maxillary arch
subdivision cases
• Extraction of single maxillary premolar
Mandibular dental midline
• First or second premolar extracted depending on extent of crowding
coincides with the facial
and midline discrepancy
midline but maxillary mid-
line is deviated • Avoid excessive tipping of anterior teeth (mesio-distal), skewing of arch
form or overcorrection of highly visible maxillary anterior dentition
Combination • Is found in about 20% Inter-arch mechanics aimed at correction of both arches
Class II subdivi- of cases
sion
• Features of both types
of class 2 subdivision
malocclusion
• Some tooth size
discrepancy found in
both arches
on closure. Upper and lower dental midlines should dimensions and quantification of facial asymmetry
be evaluated in centric relation and centric occlu- (Nute and Moss, 2000). Laser scans are used in plas-
sion. In mandibular deviation and if lower dental tic surgery to study the facial asymmetry (O’grady
midline coincides with the chin point, the skeletal and Antonyshyn, 1999).
origin of discrepancy is most likely. In the absence of
• Stereophotogrammetry is another non-invasive and
mandibular deviation and if the lower dental mid-
reproducible technique of imaging. It obtains 3D
line is not consistent with chin point, the dental ori-
images using multiple photographs of the same ob-
gin of difference is most likely. Cant in the maxillary
ject taken at different angles. It allows detection of
occlusal plane should also be assessed relative to the
changes in facial growth and development, gauging
inter-pupillary line using tongue spatula.
facial morphology and monitoring facial asymmetry
• Extraoral photographs, including frontal, profile over time.
and three-quarter profile views and the front view
• Ionising imaging includes:
of patient biting on a tongue spatula, can illustrate
transverse occlusal cant. Intraoral photographs 1. Panoramic radiograph that allows bilateral comparison
should also be taken in centric occlusion and centric of the mandibular ramus and condylar shape. However, the
relation in mandibular displacement. validity is poor due to the effect of patient positioning.
• Laser scanning is an applicable non-invasive proce- 2. Posterior-anterior cephalometric radiographs allow as-
dure that allows digitisation and comparison of im- sessment of left and right hard-tissue structures and skel-
ages and records more than 60,000 points in 10 sec- etal and dental midlines. Localisation of the asymmetry is
onds resulting in an accuracy of 0.5 mm (Moss et al., achieved by using a midsagittal reference plane.
1991). It allows examination of facial growth in three
3. Transcranial and transpharyngeal views of TMJ are used
Asymmetries 163
to analyse pathology, arthritic disease, and trauma to the in cases where the skeletal asymmetry is mild or accepted,
TMJ. and the atypical growth must have ceased. Dental midline
discrepancies can be camouflaged orthodontically by the fol-
4. Lateral cephalogram can identify vertical asymmetry in
lowing techniques:
the bilateral asymmetrical superimposition of symmetric
structures. A single ear rod is used in a natural head position • Asymmetric extraction patterns for correction.
for correct orientation in a patient with an altered ear posi-
• Asymmetric mechanics include asymmetric lace-
tion.
backs, push-pull mechanics and asymmetric use of
5. Computerised tomography provides the most detailed elastics.
visual aid to the skeletal morphology (Sievers et al., 2011).
• Asymmetric torque for correction of asymmetric
Cone beam computerized tomography images and 3D recon-
transverse relations.
structed images can help study developmental deformities
and locate the position of any bony asymmetry (White and 2. Surgical treatment
Pharoah, 2000).
• Corrective orthognathic surgery is indicated after
6. Radioisotope imaging such as short-lived gamma-emit- cessation of atypical growth. Pre-surgical orthodon-
ting isotope (Technetium 99m) is mainly indicated in Hemi- tics involves levelling and alignment accompanied
mandibular hyperplasia and Hemimandibular elongation by decompensation of arches. Correction of dental
cases. It is also used for imaging bones, salivary glands and midlines to their respective jaw (skeletal) midlines
investigation of tumour pathology (especially in the salivary is undertaken during the pre-surgical orthodontics,
glands). However, it is associated with excess radiation expo- while skeletal midlines are corrected through sur-
sure and false-negative results (Matteson et al., 1985). gery. Bilateral sagittal split osteotomy is performed
in cases of severe mandibular skeletal asymmetry. Le
• Magnetic resonance imaging can also be used to as-
Fort I osteotomy may be required to correct a trans-
sess soft tissue asymmetry.
verse occlusal cant which occurs due to compensa-
• Study models articulated with a facebow transfer tory maxillary growth. Post-surgical orthodontics
demonstrate the relationship of the jaws in 3 planes consists of detailing the occlusion and achieving in-
of space and allow assessment of the functional oc- terdigitation of the arches.
clusion in asymmetry cases.
• Distraction osteogenesis (DO) is indicated in severe
• Information obtained from CBCT/ CT scan can be asymmetric mandibular deficiency where ramus
used for stereolithographic printing models of the and body require lengthening, such as severe hemi-
facial skeleton. It is useful for planning surgery in facial microsomia or condylar fracture at an early
patients with severe facial asymmetry (Sailer et al., age causing severe restriction of translation on the
1998) (Kernan and Wimsatt, 2000). affected side (Tehranchi and Behnia, 2000)
• Special investigations such as incisional/ excisional • Adjunctive surgical procedures such as genioplasty
biopsies can be prescribed to reveal the nature of are indicated where the change in the chin’s repo-
hard or soft tissue pathology (fibro-osseous lesions sition is required in the vertical or transverse di-
or tumour-like lesions). mension. This is considered a very stable procedure
(Proffit et al., 1996). Implants or bone recontouring
Management of functional asymmetry
can be adopted to correct the asymmetric shape of
Occlusal adjustments can be performed to eliminate prema- the ramus or body of the mandible. Moreover, some
ture contacts that cause mild deviations of the mandible. An might even consider non-surgical soft tissue proce-
occlusal splint may be required to ‘deprogrammer’ habitual dures such as filler and BOTOX
displacements to aid diagnosis. Functional displacement
of the mandible due to a crossbite might require maxillary
expansion for correction. Maxillary expansion can be per-
formed using upper removable appliances with a midline ex-
pansion screw or fixed appliances incorporating a quad-helix,
auxiliary expansion arches or rapid maxillary expansion (Gill
et al., 2004).
Management of skeletal asymmetry
These include:
1. Orthodontic camouflage: This approach can be attempted
164 Asymmetries
Exam night review Traumatic factors: Condylar fractures and subsequent an-
kyloses and eventually asymmetry of the jaws (Proffit et al.,
General features
1980).
• Right side is commonly larger.
Functional factors: Centric occlusion to centric relation dis-
• Greater than 4mm of mandibular asymmetry is crepancies can lead to mandibular displacement on closure.
clinically noticeable (McAvinchey et al., 2014).
Idiopathic and iatrogenic factors
• Up to 2.2 mm of dental midline discrepancy is per-
Local factors
ceived as acceptable (Janson et al., 2011).
Classification of asymmetry
Aetiology of asymmetry
• Skeletal asymmetry affecting.
Environmental factors
• Muscular asymmetry
• Intra-uterine pressure and moulding
• Functional asymmetry secondary to TMJ dysfunc-
• Condylar hyper/hypoplasia
tion or a CO-CR shift.
• Excessive condylar growth
• Dental asymmetry
• Habits e.g. Thumb sucking
Hemifacial microsomia (HFM)
Developmental factors (Chia et al., 2008)
Congenital disorder →unilateral developmental defects in
• Hemimandibular elongation orofacial region.
• Hemimandibular hyperplasia Proposed Aetiologies for HFM
• Condylar hypo- or hyperplasia • Defect in proliferation and migration of neural crest
cells
• Hemifacial microsomia
• Hemorrhage of stapedial artery (Poswillo, 1973).
• Hemifacial hypertrophy
• Goosecoid (Gsc) - potential candidate gene for
• Hemifacial atrophy (Parry-Romberg syndrome)
Hemifacial microsomia (Kelberman et al., 2001).
• Achondroplasia
Clinical features of HFM
• Torticollis
• Mandibular asymmetry of varying severity.
• Unilateral cleft lip and palate
• Reduction in size or flattening of facial bones.
• Childhood fractures of the jaw
• Unilateral crossbite.
Pathological factors
• Disturbed tooth development.
• Tumors of orofacial region (e.g. Ameloblastoma
• Severely malformed or absent pinna of the ear.
arising in body and ramus of mandible, tumors of
condylar head including osteoma, osteochondroma, • Periauricular skin tags.
chondrosarcoma).
• Narrowed palpebral fissures.
• Cysts (e.g. Dentigerous cysts, keratocysts, lympho-
• Unilateral epibulbar dermoids.
epithelial cysts)
• Variable degrees of nerve palsy
• Fibrous dysplasia
• Cleft lip and palate, palatal and tongue muscle hypo-
• Infection (e.g. Dento-alveolar abscesses, acute par-
plasia and velopharyngeal insufficiency→ less com-
otitis)
mon.
• Decreased tonic muscular activity (cerebral palsy,
Management of HFM
muscular dystrophy, Muscle weakness syndromes)
• Growth modification using the hybrid functional
• Muscular atrophy due to damage to motor nerve
appliance.
• Condylar resorption due to juvenile rheumatoid ar-
• Reconstructive surgery→severe deformity.
thritis, post-steroid therapy and following orthogna-
thic surgery. Juvenile Rheumatoid Arthritis
Asymmetries 165
• It is a disease process that affects bone and cartilage. • It is characterised by overgrowth in the craniofacial
structures (including soft and hard tissues).
• In children with one to three affected joints, TMJ
is involved in 33% of cases, while in children with • Occlusion is also likely to be affected.
greater than four affected joints, TMJ is involved in
Examination of asymmetry
80% of cases (Ince et al., 2000).
• Extraoral clinical examination
• Progressive destruction of condyles results in short-
ening of ramus and downward and backward rota- • Intraoral clinical examinations
tion of the chin, which leads to chin deficiency and
• Non-ionizing imaging
anterior open bite.
• Ionising imaging
• Condylar resorption may occur faster on one side
than the other resulting in mandibular asymmetry • Radioisotope imaging
in two thirds to three-fourths of affected children. • Study casts
Treatment of Juvenile Rheumatoid Arthritis • Stereolithographic models
• TMJ replacement in severe cases. • Pathological special Investigations
• Functional appliances and any surgical procedure Management of functional asymmetry
which manipulates TMJ are not recommended.
• Occlusal splint
• Augmentation genioplasty
• Occlusal adjustments
• Surgical maxillary impaction
• Functional displacement of mandible due to cross-
Condylar resorption following orthognathic surgery bite requires orthodontic treatment (including max-
Predisposing factors: illary expansion) for correction.
• Preoperative temporomandibular joint dysfunction • Maxillary expansion.
(Hwang et al., 2004). Management of skeletal asymmetry
• Young and female patients (due to hormonal fac- Orthodontic camouflage: for acceptable skeletal asymmetry
tors)
• Asymmetric extraction patterns
• High mandibular plane angle with mandibular re-
trusion. • Asymmetric mechanics
Asymmetric mandibular excess • Asymmetric torque
• It is due to excessive unilateral growth of the man-
dible, which may affect its body, ramus and condyle.
Management of asymmetric mandibular excess
• In progressive deformity, surgical reduction/remov-
al of the affected condyle is indicated even in young
patients.
• Excision of bone at the head of the condyle followed
by recontouring or repositioning of the bony stump
into the glenoid fossa
• Removal of the condyle and condylar process fol-
lowed by reconstruction of TMJ either with a costo-
chondral junction transplant or a free graft (Boyne,
1989).
Hemifacial hypertrophy
• It is hypertrophy of one side of the face.
• It is mainly due to the asymmetric distribution of
neural crest cells.
166 Asymmetries
References M. R. & PINZAN, A. 2001. Three-dimensional evaluation of skel-
etal and dental asymmetries in Class II subdivision malocclusions.
ACKERMAN, J. L., PROFFIT, W. R., SARVER, D. M., ACKER-
MAN, M. B. & KEAN, M. R. 2007. Pitch, roll, and yaw: describing
119, 406-418.
the spatial orientation of dentofacial traits. American Journal of Or-
thodontics and Dentofacial Orthopedics, 131, 305-310. KELBERMAN, D., TYSON, J., CHANDLER, D., MCINERNEY, A.,
SLEE, J., ALBERT, D., AYMAT, A., BOTMA, M., CALVERT, M. &
ALAVI, D. G., BEGOLE, E. A. & SCHNEIDER, B. J. 1988. Facial
GOLDBLATT, J. 2001. Hemifacial microsomia: progress in under-
and dental arch asymmetries in Class II subdivision malocclusion.
standing the genetic basis of a complex malformation syndrome.
Human genetics, 109, 638-645.
93, 38-46.
KERNAN, B. T. & WIMSATT, J. A. 2000. Use of a stereolithogra-
BISHARA, S. E., BURKEY, P. S. & KHAROUF, J. G. 1994. Dental
phy model for accurate, preoperative adaptation of a reconstruction
and facial asymmetries: a review. The Angle Orthodontist, 64, 89-98.
plate. Journal of oral and maxillofacial surgery, 58, 349-351.
BOYNE, P. J. 1989. Free grafting of traumatically displaced or resect-
KOKICH, V. 1993. Anterior dental esthetics: an orthodontic per-
ed mandibular condyles. Journal of Oral and Maxillofacial Surgery,
spective III. Mediolateral relationships. J Esthet Dent, 5, 200-207.
47, 228-232.
LIUKKONEN, M., SILLANMÄKI, L. & PELTOMÄKI, T. 2005.
CHIA, M. S., NAINI, F. B. & GILL, D. S. 2008. The aetiology, di-
Mandibular asymmetry in healthy children. Acta Odontologica
agnosis and management of mandibular asymmetry. Orthodontic
Scandinavica, 63, 168-172.
Update, 1, 44-52.
MADRID, J. R. P., MONTEALEGRE, G. & GOMEZ, V. 2010. A new
COUSLEY, R. & CALVERT, M. 1997. Current concepts in the un-
classification based on the Kaban’s modification for surgical man-
derstanding and management of hemifacial microsomia. British
agement of craniofacial microsomia. Craniomaxillofacial Trauma &
journal of plastic surgery, 50, 536-551.
Reconstruction, 3, 1-7.
DEGUZMAN, L., BAHIRAEI, D., VIG, K., VIG, P., WEYANT, R.
MATTESON, S. R., PROFFIT, W. R., TERRY, B. C., STAAB, E. V. &
& O’BRIEN, K. 1995. The validation of the Peer Assessment Rating
BURKES JR, E. J. 1985. Bone scanning with99mtechnetium phos-
index for malocclusion severity and treatment difficulty. American
phate to assess condylar hyperplasia: Report of two cases. Oral sur-
Journal of Orthodontics and Dentofacial Orthopedics, 107, 172-176.
gery, oral medicine, oral pathology, 60, 356-367.
ESLAMI, B., BEHNIA, H., JAVADI, H., KHIABANI, K. S. & SAF-
MCAVINCHEY, G., MAXIM, F., NIX, B., DJORDJEVIC, J., LIN-
FAR, A. S. 2003. Histopathologic comparison of normal and hyper-
KLATER, R. & LANDINI, G. 2014. The perception of facial asym-
plastic condyles. Oral Surgery, Oral Medicine, Oral Pathology, Oral
metry using 3-dimensional simulated images. The Angle orthodon-
Radiology, and Endodontology, 96, 711-717.
tist, 84, 957-965.
FERGUSON, J. W. 1993. Surgical correction of the facial deformities
MELNIK, A. K. 1992. A cephalometric study of mandibular asym-
secondary to untreated congenital muscular torticollis. Journal of
metry in a longitudinally followed sample of growing children.
Cranio-Maxillofacial Surgery, 21, 137-142.
GILL, D., NAINI, F., MCNALLY, M. & JONES, A. 2004. The man- 101, 355-366.
agement of transverse maxillary deficiency. Dental update, 31, 516-
MONAHAN, R., SEDER, K., PATEL, P., ALDER, M., GRUD, S. &
523.
O’GARA, M. 2001. Hemifacial microsomia: etiology, diagnosis and
HWANG, S.-J., HAERS, P. E., SEIFERT, B. & SAILER, H. F. 2004. treatment. The Journal of the American Dental Association, 132,
Non-surgical risk factors for condylar resorption after orthognathic 1402-1408.
surgery. Journal of cranio-maxillofacial surgery, 32, 103-111.
MOSS, J., COOMBES, A., LINNEY, A. & CAMPOS, J. 1991. Meth-
INCE, D. O., INCE, A. & MOORE, T. L. 2000. Effect of methotrexate ods of three dimensional analysis of patients with asymmetry of the
on the temporomandibular joint and facial morphology in juvenile face. Proceedings of the Finnish Dental Society. Suomen Hammas-
rheumatoid arthritis patients. American Journal of Orthodontics laakariseuran Toimituksia, 87, 139-149.
NUTE, S. J. & MOSS, J. P. 2000. Three-dimensional facial growth
JANSON, G., BRANCO, N. C., FERNANDES, T. M. F., SATHLER, studied by optical surface scanning. J Orthod, 27, 31-8.
R., GARIB, D. & LAURIS, J. R. P. 2011. Influence of orthodontic
O’GRADY, K. F. & ANTONYSHYN, O. M. 1999. Facial asymmetry:
treatment, midline position, buccal corridor and smile arc on smile
three-dimensional analysis using laser surface scanning. Plastic and
attractiveness: A systematic review. The Angle orthodontist, 81, 153-
reconstructive surgery, 104, 928-937.
161.
OBWEGESER, H. L. & MAKEK, M. S. 1986. Hemimandibular hy-
JANSON, G., DE LIMA, K. J. R. S., WOODSIDE, D. G., METAXAS,
perplasia—hemimandibular elongation. Journal of maxillofacial
A., DE FREITAS, M. R. & HENRIQUES, J. F. C. 2007. Class II sub-
surgery, 14, 183-208.
division malocclusion types and evaluation of their asymmetries.
American journal of orthodontics and dentofacial orthopedics, 131, PECK, S., PECK, L. & KATAJA, M. 1991. Skeletal asymmetry in es-
57-66. thetically pleasing faces. The Angle Orthodontist, 61, 43-48.
JANSON, G. R., METAXAS, A., WOODSIDE, D. G., DE FREITAS, POSWILLO, D. 1973. The pathogenesis of the first and second bran-
Asymmetries 167
chial arch syndrome. Oral surgery, oral medicine, oral pathology,
35, 302-328.
PROFFIT, W., TURVEY, T. & PHILLIPS, C. 1996. Orthognathic
surgery: a hierarchy of stability. The International journal of adult
orthodontics and orthognathic surgery, 11, 191-204.
PROFFIT, W. R., VIG, K. W. & TURVEY, T. A. 1980. Early frac-
ture of the mandibular condyles: frequently an unsuspected cause
of growth disturbances. American journal of orthodontics, 78, 1-24.
ROSE, J. M., SADOWSKY, C., BEGOLE, E. A. & MOLES, R. 1994.
Mandibular skeletal and dental asymmetry in Class II subdivision
malocclusions. American Journal of Orthodontics and Dentofacial
SAILER, H., HAERS, P., ZOLLIKOFER, C., WARNKE, T., CARIS,
F. & STUCKI, P. 1998. The value of stereolithographic models for
preoperative diagnosis of craniofacial deformities and planning of
surgical corrections. International journal of oral and maxillofacial
surgery, 27, 327-333.
SANDERS, D. A., RIGALI, P. H., NEACE, W. P., URIBE, F. & NAN-
DA, R. 2010. Skeletal and dental asymmetries in Class II subdivision
malocclusions using cone-beam computed tomography. American
Journal of Orthodontics and Dentofacial Orthopedics, 138, 542. e1-
542. e20.
SCHMID, W., MONGINI, F. & FELISIO, A. 1991. A computer-
based assessment of structural and displacement asymmetries of
the mandible. American Journal of Orthodontics and Dentofacial
SIEVERS, M. M., LARSON, B. E., GAILLARD, P. R. & WEY, A.
2011. Asymmetry assessment using cone-beam CT: A Class I and
Class II patient comparison. The Angle Orthodontist, 82, 410-417.
SLOOTWEG, P. J. & MÜLLER, H. 1986. Condylar hyperplasia. A
clinico-pathological analysis of 22 cases. Journal of maxillofacial
surgery, 14, 209-214.
TEHRANCHI, A. & BEHNIA, H. 2000. Treatment of mandibular
asymmetry by distraction osteogenesis and orthodontics: a report of
four cases. The Angle Orthodontist, 70, 165-174.
TURVEY, T., RUIZ, R., BLAKEY III, G., BIRON, R. & LEVIN, L.
2004. Management of facial fractures in the growing patient. Fon-
seca RJ, Walker RV, Betts NJ. Oral and Maxillofacial Trauma. 3rd ed.
St Louis, MO: Elsevier Saunders, 967-1000.
VIG, P. S., ORTH, D. & VIG, K. W. 1986. Hybrid appliances: a com-
ponent approach to dentofacial orthopedics. American Journal of
WHITE, S. & PHAROAH, M. 2000. Specialized radiographic tech-
niques. Oral radiology principles and interpretation (5th edn). St
Louis, MO: CV Mosby, 255-260.
168 Asymmetries
High Angle Cases
17
In this Chapter
1. Aetiology of high angle cases
2. Clinical features
3. Radiographical features
4. Clinical implications in treating high angle
5. Treatment considerations
H igh angle in orthodontics refers to increased vertical pro-
• Increased overjet.
Radiographical features
portions of face. In cephalometric analysis, if vertical values
are above one standard deviation, then the case is considered The main cephalometric features of high angle cases include
high angle. Cephalometric values used to diagnose high angle increased mandibular inclination in relation to anterior cra-
are: nial base, excessive lower facial height, small posterior facial
• MMPA greater than 29˚. height and large gonial and mandibular plane angle. Other
structural features of high angle cases as per Bjork are (Ski-
• FMPA greater than 32˚. eller et al., 1984)(Björk, 1969):
• LAFH greater than 57%. • Decreased inter-molar and inter-premolar angle.
• SN-Mandibular plane greater than 36˚. • Decreased interincisal angle (acute).
• SN-Palatal plane greater than 10˚. • Increased lower anterior facial height.
• Sum of inner angles are greater than 400˚. • Forward inclination of the mental symphysis.
• Y-axis angle greater than 70˚. • Backward inclination of the condylar head.
• Jarabak ratio greater than 61%. • Steep curvature of the mandibular canal.
• Overbite depth indicator less than 68˚ (Fatima et al., • Prominent antegonial notch.
2016).
Clinical implications in treating high angle
Aetiology of high angle cases
These include:
High angle cases cover a number of conditions including long
face syndrome, backward growth rotations, anterior open • High angle patients can present with a reduced
bite and open bite tendency. The main aetiological factors are: overbite or an anterior open bite which is difficult to
control.
• Unfavorable vertical/ backward growth pattern.
• A steep occlusal plane in high angle cases is associ-
• Hereditary factors, e.g. increased tongue size and ated with higher anchorage demand compared with
abnormal growth pattern of mandible and maxilla. low angle cases.
• Thumb sucking habit, which causes an anterior open • The reduced bone quality (Johari et al., 2015) and
bite along with a backward rotation of the mandible the reduced buccolingual alveolar bone thickness
(Ngan and Fields, 1997). (Lee et al., 2018) explain the poor primary stabil-
• Tongue thrust habit. ity and high failure rate of miniscrews in high angle
cases.
• Prolonged mouth breathing, leading to over-devel-
opment of posterior dentoalveolar height. • High angle cases have a marked ANB discrepancy
(Class II skeletal pattern) due to downward and
• Orofacial matrices malfunction due to an imbalance backward rotation of the mandible. Clockwise ro-
between jaw posture, occlusion, eruptive forces and tation of the mandible increases the lower anterior
head position. This imbalance leads to a downward face height and lead to retroclination of the lower
and backward rotation of the mandible. incisors and subsequently lower labial segment
Clinical features of high angle cases crowding (Betzenberger et al., 1999). Therefore, any
treatment mechanics that might cause backwards
These include: rotation of the mandible should be avoided.
• Tapered facial type. • Short roots have been observed with a reduced
• Increased lower anterior facial height. crown/root ratio (Uehara et al., 2013).
• Decreased upper anterior facial height. Treatment considerations
• Steep mandibular plane angle. These include:
• Commonly short ramus. • It is essential to eliminate all aetiologies before treat-

ment, for example, digit sucking.
• Class II skeletal relationship.
• Minimising the use of Class II elastics and bite
• Decreased overbite. opening appliances are advisable.
170 High Angle

• Posterior anchorage should be carefully planned Bjork’s seven signs of high angle cases
and reinforced.
• Increased intermolar and interpremolar angle.
• Minimising lower labial segment proclination is es-
• Decreased interincisal angle (acute).
sential as this might negatively affect the overbite
(Houston, 1988). • Increased lower anterior facial height.
• A transpalatal arch with high pull headgear to avoid • Prominent antegonial notch.
upper molar extrusion and prevent the palatal cusps
• Forward inclination of the mental symphysis.
from dropping down is recommended (Scheffler et
al., 2014, Ishida and Ono, 2017). The intrusion of • Backward inclination of the condylar head.
maxillary posteriors could provide satisfactory oc- • Steep curvature of the mandibular canal.
clusion if an open bite is present. Hence, miniscrew
anchorage is recommended (Wang et al., 2016). Treatment considerations
• In growing patients, a Herbst appliance attached to • LLS proclination (Houston, 1988).
an acrylic splint, along with high pull headgear, can
successfully treat high angle Class II patients (Schia- • Elimination of aetiology
voni et al., 1992). • Minimise +ve growth rotation.
• High angle cases of skeletal origin are challenging to
treat. Therefore a combination of orthodontic treat- • Anchorage demands.
ment and orthognathic surgery can be indicated • Avoid extrusive mechanics on posterior teeth.
(Torgersbraten et al., 2019).
• TPA with high pull headgear
• Intrusion of maxillary posteriors →if open bite.
Exam night review

Cephalometric values used to diagnose high angle are:
• MMPA is greater than 29˚.
• FMPA is greater than 32˚.
• LAFH is greater than 57%.
• SN-Mandibular plane greater than 36˚.
• SN-palatal plane is greater than 10˚.
• Sum of inner angles is greater than 400˚.
• Y-axis angle greater than 70˚.
• Jarabak ratio is greater than 69%.
• Overbite depth indicator less than 68˚ (Fatima et al.,
2016).
Aetiology
• Unfavourable vertical/backward growth pattern.
• Hereditary factors.
• Thumb sucking habit.
• Tongue thrust habit.
• Prolong mouth breathing.
• Orofacial matrices malfunction.
High Angle 171

References
BETZENBERGER, D., RUF, S. & PANCHERZ, H. 1999. The com-
pensatory mechanism in high-angle malocclusions: a comparison
of subjects in the mixed and permanent dentition. Angle Orthod,
69, 27-32.
DUNG, D. J. & SMITH, R. J. 1988. Cephalometric and clinical
diagnoses of open bite tendency. Am J Orthod Dentofacial Orthop,
94, 484-90.
FATIMA, F., FIDA, M. & SHAIKH, A. 2016. Reliability of overbite
depth indicator (ODI) and anteroposterior dysplasia indicator
(APDI) in the assessment of different vertical and sagittal dental
malocclusions: a receiver operating characteristic (ROC) analysis.
Dental Press J Orthod, 21, 75-81.
HOUSTON, W. J. B. 1988. Mandibular growth rotations—their
mechanisms and importance. European Journal of Orthodontics,
10, 369-373.
ISHIDA, Y. & ONO, T. 2017. Nonsurgical treatment of an adult
with a skeletal Class II gummy smile using zygomatic temporary
anchorage devices and improved superelastic nickel-titanium alloy
wires. Am J Orthod Dentofacial Orthop, 152, 693-705.
JOHARI, M., KAVIANI, F. & SAEEDI, A. 2015. Relationship
Between the Thickness of Cortical Bone at Maxillary Mid-palatal
Area and Facial Height Using CBCT. Open Dent J, 9, 287-91.
LEE, S., HWANG, S., JANG, W., CHOI, Y. J., CHUNG, C. J. &
KIM, K. H. 2018. Assessment of lower incisor alveolar bone width
using cone-beam computed tomography images in skeletal Class
III adults of different vertical patterns. Korean J Orthod, 48, 349-
356.
MONACO, A., STRENI, O., MARCI, M. C., MARZO, G., GATTO,
R. & GIANNONI, M. 2004. Gummy smile: clinical parameters use-
ful for diagnosis and therapeutical approach. J Clin Pediatr Dent,
29, 19-25.
NGAN, P. & FIELDS, H. W. 1997. Open bite: a review of etiology
and management. Pediatr Dent, 19, 91-8.
SCHEFFLER, N. R., PROFFIT, W. R. & PHILLIPS, C. 2014. Out-
comes and stability in patients with anterior open bite and long
anterior face height treated with temporary anchorage devices and
a maxillary intrusion splint. Am J Orthod Dentofacial Orthop, 146,
594-602.
SKIELLER, V., BJORK, A. & LINDE-HANSEN, T. 1984. Predic-
tion of mandibular growth rotation evaluated from a longitudinal
implant sample. Am J Orthod, 86, 359-70.
UEHARA, S., MAEDA, A., TOMONARI, H. & MIYAWAKI, S.
2013. Relationships between the root-crown ratio and the loss of
occlusal contact and high mandibular plane angle in patients with
open bite. Angle Orthod, 83, 36-42.
WANG, X. D., ZHANG, J. N., LIU, D. W., LEI, F. F. & ZHOU, Y.
H. 2016. Nonsurgical correction of a severe anterior deep overbite
accompanied by a gummy smile and posterior scissor bite using a
miniscrew-assisted straight-wire technique in an adult high-angle
case. Korean J Orthod, 46, 253-65.
172 High Angle

Anterior open bite
18
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam, Eesha Muneeb, Muhammad Qasim Saeed
In this Chapter
1. Aetiology of Anterior open bite (AOB) 19. Kim mechanics
2. Classification of AOB 20. Modified Kim mechanics
3. Incidence of AOB 21. Molar intrusion using skeletal anchorage
4. Predictors of skeletal open bite 22. Treatment considerations of AOB treated with
5. Features of skeletal open bite molar intrusion
6. Justifications for treatment of AOB 23. Rapid molar intrusion device (RMI)
7. Aetiology of AOB 24. Advantages and disadvantages of RMI
8. Digit Sucking Habit 25. Repelling magnets for the treatment of OAB
9. Long term effects of pacifier and dummy suck 26. Orthognathic option for management of skeletal
ing habit AOB
10. Management of digit-sucking habits 27. Factors contributing to skeletal relapse
11. Types of removable habit breakers 28. Adjunctive procedures
12. Types of fixed habit breakers 29. Stability of AOB treatment
13. Management of mouth breathing 30. Causes of relapse
14. Management of secondary tongue thrust 31. Retention of treated AOB cases
15. Myofunctional therapy for the treatment of AOB 32. Methods for retention
16. Combined myofunctional and extraoral appli 33. Difficulty associated with the treatment of AOB
ance combination therapy 34. Posterior open bite
17. Extraoral appliance for management of AOB 35. EXAM NIGHT REVIEW
18. Treatment principles in the management of AOB
using fixed appliances
A OB is defined as a vertical discrepancy with no contact
•
canine but does not include premolars
Compound open bite – when the open bite extends
between anterior teeth in centric relation or lack of vertical
overlap of the upper incisors’ with the lower incisor crowns from premolar to premolar but does not include mo-
when the posterior teeth are in occlusion (Houston et al., lars
1992). • Infantile open bite – open bite which includes mo-
Openbite can also be described as a vertical space between lars
maxillary and mandibular incisors perpendicular to the 4. Based on the morphology of the skeletal pattern (Kim,
functional occlusal plane and is quantified by overbite mea- 1974), which include:
surement from the opposing dentition with the largest verti-
• Dentoalveolar open bite – when the mandible ap-
cal discrepancy.
pears to be normal
Aetiology of AOB
• Skeletal open bite - when the mandible appears ab-
The aetiology can be skeletal, dental or soft tissue or a com- normal
bination. A severe open bite is due to a marked divergence of
5. Based on aetiological and skeletal considerations, (Rich-
skeletal planes. The range of severity varies, as it may be local-
ardson, 1981) include:
ised, affecting only a few teeth with a below-average overbite,
an edge-to-edge occlusion, or a definite space between the • Transitional open bite
upper and lower incisors.
• AOB due to habits such as digit sucking
• Dental (functional) anterior open bite is localised
• AOB due to local pathologies such as cysts, dilacera-
to anterior teeth in occlusion. The skeletal vertical
tions, and ankylosis
proportions and surrounding soft tissues are usually
normal. • AOB due to skeletal pathologies (de novo open bite)
such as cleft palate, craniofacial dysostosis, cleido-
• Skeletal open bite occurs when the primary aetiolo-
cranial dysostosis and achondroplasia
gy of an anterior open bite is a hyperdivergent facial
growth pattern, which is an excessive divergence of • Non-pathological skeletal group (ab initio open
the maxillary, occlusal, and mandibular planes about bite)
each other and the anterior cranial base (Sassouni,
• AOB due to morphology and behaviour of the
1969). It may also be referred to as apertognathia
tongue and lips
(Naini, 2011). A skeletal open bite may be caused
either by forwarding rotation (upward tipping) of a 6. Other classification (Rakosi and Jonas, 1993) include:
palatal plane or by downward tipping of the man- • Pseudo open bite – occurs in the presence of incisor
dibular plane. protrusion
Classification of AOB • Infantile open bite - involves all teeth, including mo-
These include: lars
1. Based on aetiology: developmental or acquired (Shira, • Iatrogenic open bite - occurs due to erroneous orth-
1961) odontic treatment
2. Based on site (anterior or lateral) and pattern (alanting or Incidence of AOB
angulated) (Thoma, 1943) The prevalence of AOB increases to 36.3% when the ante-
3. Based on severity and extent of involvement, (Worms et rior open bite is associated with sucking habits in the mixed
al., 1971) include: dentition (Cozza et al., 2005), it ranges from 17% to 18% of
children in the mixed dentition (Cozza et al., 2005, da Silva
• Transitional open bite – open bite that occur dur-
Filho et al., 1990, Tausche et al., 2004). AOB is more com-
ing mixed dentition when the permnant incisors are
mon in Africans and Africa-Caribbeans with a prevalence of
erupting.
5% (Noar and Portnoy, 1991). There is a marked difference
• True open bite – open bite without any vertical over- in the prevalence of dental open bite among black and white
lap as well as no contact between between upper and children in the USA, affecting approximately 16% of the black
lower incisors population and only 4% of the white population (Kelly et al.,
1973). In Scotland, the incidence is 4% amongst adults (Todd
• Simple open bite – when the open bite is 1 mm or
and Whitworth, 1974). In the UK, open bite affects 4% of
greater in centric relation extending from canine to
children by 9 years of age. However the incidence falls to 2%
174 Open Bite

by the early teenage year’s (O’BRIEN et al., 1994), indicating to posterior vertical maxillary excess
a marked decrease from childhood until adolescence (Worms
• Reduced posterior face height (reduced mandibular
et al., 1971).
ramus height) -In patients with average lower ante-
Predictors of skeletal open bite rior face height, the anterior to posterior face height
ratio is increased.
These include:
• Maxilla, along with maxillary occlusal plane, tilted
A. Bjork’s structural signs of backward/posterior man-
down posteriorly, resulting in an anticlockwise rota-
dibular growth rotation (Björk, 1969) such as”
tion of the maxilla.
• A backwards inclination of the condylar head
• Posterior (backward, clockwise) growth rotation of
• The curvature of the mandibular canal is flat/straight the mandible (Bjork, 1969).
• Prominent antegonial notch • Class II tendency with retrusive mandible (Lopez-
Gavito et al., 1985)
• The mandibular symphysis is inclined backwards
and the chin is flattened and receding. • Sagittal mandibular excess or deficiency may be pri-
mary but present along with a skeletal anterior open
• The interincisal, inter-premolar and intermolar an-
bite.
gles are all decreased
• Sagittal discrepancy can also be secondary to the
• The lower anterior face height is increased, and
vertical skeletal growth pattern; for example a nor-
there is an anterior open bite
mal mandible may rotate downwards and backwards
• PFH: AFH ratio (Jarabak ratio) (Jarabak and Fiz- about posterior vertical maxillary excess (class 1 ro-
zell, 1972, Siriwat and Jarabak, 1985): PFH to AFH tate to a class 2).
ratio of 59% to 63% was defined as a neutral range. A
2. Cephalometric features such as:
ratio of 64% or more significant was defined as a low
angle case/ hypodivergent grower with a deep over- • Sometimes, enlarged adenoids
bite. A ratio of 58% or less was described as a high
• Obtuse saddle angle (formed between the anterior
angle case/ hyperdivergent grower with a reduced
and middle cranial fossae)
overbite
• Steep anterior cranial base & shorter nasion-basion
• UAFH: LAFH ratio (Nahoum, 1975, Nahoum,
distance (Lopez-Gavito et al., 1985)
1977, Nahoum et al., 1972, Nahoum, 1971): The ideal
value for this ratio is 0.82. UAFH: LAFH ratio below • Divergent cephalometric planes, excessive gonial,
0.65 indicates extreme vertical skeletal discrepancy, mandibular, and occlusal plane angles, decreased
characterised by long lower face height and open palatal plane angle (Lopez-Gavito et al., 1985)
bite tendency. It is considered a poor prognostic fac-
• Area of convergence of horizontal facial planes is
tor for conventional orthodontic treatment alone. It
positioned in front of the occiput, toward the face,
generally requires surgical intervention combined
and the planes diverge anteriorly (Sassouni, 1969,
with orthodontic treatment for a successful resolu-
Naini, 2011)
tion.
• Increased dentoalveolar height in the molar region
B. Overbite depth indicator (Kim, 1974): It is defined as
compared to incisor region due to weaker muscula-
the angle of the A-B plane to the mandibular plane combined
ture in high angle cases allowing greater eruption of
with the angle of the palatal plane to Frankfort horizontal. If
upper molars. (Nielsen, 1991, Moller, 1966, Ingervall
the latter angle is positive, it is added to the former angle. If
and Thilander, 1974).
it is negative, it is subtracted from the former angle. A value
of 68˚ or less was used to indicate open bite tendency. Ac- • Excessive eruption of maxillary and mandibular in-
cording to Dung and Smith, the overbite depth indicator was cisors
statistically significant in the occurrence of an open bite ten-
• Bjork’s seven features of posterior growth rotation
dency during the treatment (Dung and Smith, 1988).
(Björk, 1969)
Features of skeletal open bite
• Increased lower anterior facial height and compara-
These include: tively short posterior facial height (Sassouni and
Nanda, 1964, Enunlu, 1974) Jaraback ratio of 58% or
1. Skeletal features such as:
less (Jarabak and Fizzell, 1972, Siriwat and Jarabak,
• Increased lower anterior face height – Often related 1985)
Open Bite 175

• UAFH-LAFH ratio below 65% (Nahoum, 1975, Na- • Maxillary, occlusal and palatal planes tilt upwards,
houm, 1977, Nahoum et al., 1972, Nahoum, 1971) the mandibular occlusal plane tilted downwards
• Overbite depth indicator value of 68 or less (Kim, • Narrow maxilla and posterior crossbite
1974)
Justifications for treatment of AOB
These include:
• Tapering face
• Difficulty in incising food due to a lack of anterior
• Long lower third of the face occlusion,
• Retruded chin • Speech problems such as lisping – treatment of an-
terior open bite do not guarantee an improvement of speech
• Incompetent lips (resting lip separation ≥ 4 mm)
(Ferguson, 1995)
• Inadequate lip seal (Bell, 1971)
• Dental and facial appearance.
• Narrow nose
Aetiology of AOB
• Narrow alar bases
1. Skeletal factors such as:
• Obtuse nasolabial angle & the upper lip posterior-
• Excessive increase in lower anterior face height
ly inclined (particularly in class 2 skeletal pattern)
(usually due to posterior vertical maxillary excess),
(Naini et al., 2015)
with the incisors unable to erupt due to increased
• Average or increased maxillary incisor exposure face height, resulting in an anterior open bite.
about upper lip – when maxillary incisors have
• According to Richardson, lower anterior face height
reached their eruptive potential but have been un-
was considerably greater in anterior open bite cases
able to meet the opposing mandibular incisors due
than deep overbite (Richardson, 1967).
to the excessive increase in lower anterior face height
• Reduction in mandibular ramus height results in an
• Reduced maxillary incisor display or ‘no tooth
increased anterior to posterior face height ratio, a
show’ smile in extreme cases – due to the restrictive
steep mandibular plane angle, a clockwise rotation
effect of a forward, resting tongue position, result-
of the mandible, and an anterior open bite leading to
ing in anterior dentoalveolar vertical maxillary defi-
a skeletal open bite.
ciency (if there is a significant additional soft‑tissue
element to the aetiology of a skeletal anterior open • Unfavourable growth patterns (Bell, 1971, Nahoum,
bite) 1977): Vertical facial growth tendency is predomi-
nantly genetically determined as compared to hori-
• Tongue thrust type swallowing pattern to acheive a
zontal growth, but environmental influences may
lip seal.
result in additional changes, for example worsening
4. Extraoral features (Cangialosi, 1984) such as: of an anterior open bite in some cases (Enlow and
Hunter, 1968).
• Long face
2. Environmental factors such as:
• Lip incompetence
• Inflammatory - Juvenile rheumatoid arthritis in-
• Steep Frankfurt mandibular plane angle
volving the temporomandibular joint before the age
• Marked antegonial notch of 16 years can develop a severe Class II malocclu-
• Increased anterior face height sion and anterior open bite due to restricted man-
dibular growth.
5. Intraoral features such as:
• Hormonal - Overproduction of growth hormone
• Mild crowding with upright incisors (tend to exhibit due to a tumour in the anterior pituitary gland
crowding in the lower arch) causes gigantism in children and acromegaly in
• May occlude only on second molars in severe cases adults. The patient presents with a worsening class 3
malocclusion characterised by excessive mandibular
• Gingival hypertrophy due to mouth breathing growth and a significant anterior open bite in both
• Mesial tipping of molars, resulting in rotation of the situations.
occlusal plane (Kim, 1987) • Traumatic: Bilateral condylar fractures, especially
in a growing patient, possibly leading to temporo-
176 Open Bite

mandibular joint ankylosis (Loukota and McCann, Sakuda, 1964, Diamond, 1980) and excessive long
2003). Le Fort II and III fracture cases present gag- term mouth breathing can affect the facial charac-
ging occlusion and anterior open bite (Killey, 1983, teristics by increasing the vertical pattern of facial
Killey and Banks, 1987). growth, causing downward and backward postur-
ing of the mandible, downward positioning of the
• Habit such as digit sucking habit, pacifier and dum-
tongue, overeruption of the posterior teeth in both
my sucking habit.
dental arches and increasing the likelihood of open
3. Local dental factors such as: bites and crossbites. (Linder-Aronson, 1970, Linder-
Aronson, 1973, Linder-Aronson, 1983, Behlfelt et
• Transitional physiological factors - as the permanent
al., 1990, Woodside et al., 1991, Linder-Aronson,
incisors are erupting
1974, Harvold et al., 1972, Ricketts, 1968, Sankey et
• Local pathology such as supernumerary tooth – al., 2000, Gois et al., 2008, Melsen et al., 1987). The
may prevent the eruption of maxillary incisors facial appearance of such individuals was referred to
• Localized failure of development of anterior teeth as ‘adenoid facies’. (Vig, 1998)
• Over eruption of posterior teeth • Chronic allergic rhinitis associated with non-nu-
tritive sucking habits or bottle-feeding have been
• Proclination of incisors linked to anterior open bite and a posterior crossbite
4. Pathological factors such as: malocclusion in preschool children aged 4 to 5 years
(Vázquez-Nava et al., 2006). Studies of individuals
• Idiopathic condylar resorption after orthognathic with obstructive sleep apnea (Kikuchi et al., 2002)
surgery – risk factors include a female patient with and mouth breathing (Juliano et al., 2005) have
mandibular retrognathism associated with a high found a distinctive cephalometric pattern, which in-
mandibular plane angle, pretreatment condylar at- cludes long face and increased lower anterior facial
rophy, and undergoing posterior condylar displace- height, suggesting a hyper divergent pattern of skel-
ment and upward and forward rotation of the man- etal open bite (Frankel and Frankel, 1983). Accord-
dible at the time of surgery (Gill et al., 2008). ing to some studies, prolonged mouth-breathing due
• Neuromuscular conditions such as cerebral palsy to tonsillar or adenoidal obstruction may be a con-
and muscular dystrophy – where poor soft tissue tributory factor towards malocclusion, but it is not
tone may contribute to posterior growth rotation of thought to be the main causative factor (Sandler et
the jaws and an appreciable anterior open bite. al., 2011) and the effects of the mode of breathing on
facial morphology were unsupported according to
• According to Gershater, there is a high incidence Shanker 2004 (Shanker et al., 2004). An association
(32.3%) of anterior open-bite in mentally retarded between open bite, respiratory pattern, sleep respira-
and emotionally disturbed children where problems tory disturbance and snoring still needs to be deter-
in controlling the tongue at rest or in function are mined (Ali et al., 1993, Gottlieb et al., 2003, O’Brien
experienced. (Gershater, 1972) et al., 2004, Smedje et al., 2001)
• Systemic conditions such as systemic lupus erythe- • Masticatory muscles: A relationship between weak
matosus resulting in condylysis; cleft palate. musculature and a hyperdivergent growth pattern
5. Iatrogenic factors such as: (Proffit and Fields, 1983, Ringqvist, 1973). Mastica-
tory muscles in long face patients associated with
• Poorly controlled extrusive orthodontic forces on anterior open bite are likely to have low volume
the posterior teeth, resulting in extrusion of upper (Rowlerson et al., 2005). The smaller muscle fibers
molars and opening of the bite anteriorly in high (shorter and thinner masseter muscles) can gener-
angle cases. ate less bite force. In contrast, increasing volume of
• Use of anterior bite plane in cases with a reduced muscle, long thick masseter muscle with larger fibres
overbite. is associated with anterior growth direction, larger
posterior face height, and deep bite in short face in-
6. Soft tissue factors such as: dividuals (Proffit et al., 1983, Benington et al., 1999,
• Nasorespiratory function and head posture: Pos- Hunt and Cunningham, 1997, Ingervall and Helki-
tural changes to the head due to chronic partial na- mo, 1978, Kiliaridis et al., 1995, Corruccini, 1984).
sal airway obstruction (Solow and Tallgren, 1976), • Tongue size, resting position and/or activity includ-
hypertrophic nasopharyngeal tissues (adenoids, ing:
tonsils) or enlarged lymphatic tissue (Subtelny and
Open Bite 177

a) Tongue size – Pathology of tongue size can co-exist with Non-nutritive sucking behaviour is very common in the in-
anterior open bite malocclusion. Macroglossia (for example, fant (Mizrahi, 1978, Subtelny and Sakuda, 1964). The inci-
in Beckwith-Wiedmann and Down’s syndrome) or ankylo- dence of digit sucking decreases from 30% at 1 year of age
glossia can be due to local or systemic factors; normalisation to 12% at the age of 9 and only 2% by the age of 12 years
of tongue volume in such cases is essential (Ingervall and (Brenchley, 1992). Prolonged digit sucking is more common
Schmoker, 1990). Closure of anterior open bite is unlikely to in females (Brenchley, 1992). The severity of the resulting
be stable in these cases; tongue reduction surgery may have to malocclusion depends on the patient’s age, intensity, frequen-
be considered in cases of macroglossia, but it is uncommon, cy, and duration of the habit into the permanent dentition
resection of an anterior V-shaped wedge and an oval mid- (Larsson, 1987).
line excision from anterior to the vallate papillae (Naini et al.,
Persistent digit-sucking (greater than 6 hours) is associated
2016) described by Egyedi and Obwegeser (Egyedi, 1964) is a
with a significant malocclusion, and the effects are often seen
more helpful technique.
in the permanent dentition due to the continuation of the
b) Tongue posture: A correlation between tongue position habit. Dentoalveolar discrepancies caused by prolonged digit
and anterior open bite pattern has been suggested (Straub, sucking include asymmetrical anterior open bite, interfer-
1960). A forward, resting tongue position (between the inci- ence with the eruption of incisors, and proclination of upper
sor teeth) may hinder the development of the anterior ver- incisors resulting in an increased overjet and retroclination
tical dentoalveolar dimension, resulting in an anterior open of lower incisors, narrowing of the maxillary arch along with
bite with the incisors at a different vertical level to the pos- buccal crossbite with or without lateral mandibular displace-
terior teeth along with a reverse curve of Spee in the lower ment. Thumb sucking precipitates downwards movement
arch. According to Proffit, the resting position of the tongue of mandible resulting in separation of teeth, with 1 mm of
has a much stronger influence on tooth position than any vertical growth posteriorly (due to over eruption of posterior
tongue thrust, as the duration of thrusting activity would be teeth) opens the bite 2 mm anteriorly (Proffit et al., 2007).
too short of having a significant effect (Proffit, 1978)
Self-correction of anterior open bite is possible if the habit
c) Swallowing pattern: An unusual adaptive swallowing pat- stops before 9 years of age; spontaneous correction is un-
tern (secondary/adaptive tongue thrust) – tongue is thrust likely if prolonged beyond the pubertal growth spurt (Lars-
forward to maintain an anterior seal during swallowing as son, 1987). After stopping the habit, a significant proportion
an adaptive response to the presence of an anterior open bite of cases improve spontaneously (Finlay and Richardson,
to prevent food/liquid/saliva escaping from the front of the 1995), usually during the transition from the mixed to the
mouth (Subtelny, 1965). permanent dentition (Ferguson, 1995). Normalisation of the
overbite can take between 3 to 5 years (Bowden, 1966), but
d) Activity - Endogenous (primary) tongue thrust is an ex-
spontaneous correction of the transverse discrepancy is not
tremely rare condition and affects only 1% of the population.
likely (Proffit et al., 2007)
It is usually associated with an underlying abnormality in
the neuromuscular control of the tongue and excessive cir- Long term effects of pacifier and dummy sucking habit
cumoral contraction on swallowing (for example, in Down’s
These include:
syndrome). So the open bite is difficult to correct. There is
a high tendency to relapse after treatment since the existing • Dental effects are primarily observed in the decidu-
soft tissue/tongue habits will not necessarily change, despite ous dentition. The majority of dummy sucking hab-
a change in the occlusion. The typical oral features: are (Bal- its are self-limiting, and children stop using them
lard, 1961): before the eruption of permanent teeth & long-term
effects are negligible. The severity of anterior open
i. Bimaxillary incisor proclination
bite is related to the time of use of the pacifier (Lars-
ii. Symmetrical anterior open bite son, 1986).
iii. A significant portion of the tongue is constantly pres- • Long term use of a pacifier may postpone the erup-
ent between the anterior teeth – reducing their eruption and tion of incisors resulting in an open bite as well as
causing intrusion. proclination of upper incisors, narrowing of the up-
per arch, increased muscular activity on canines and
iv. Reverse curve of Spee in the lower arch and an accentu-
reduced activity on molars leading to a posterior
ated curve in the upper arch
crossbite (self-correction of posterior crossbite oc-
v. Significant sigmatism (sibilant lisping) curs if the habit stops before 4 years of age and the
contact between upper and lower incisors is repaired
vi. Usually, normal face height.
resulting in resolution of open bite). (Adair, 2003,
Digit Sucking Habit Cadden, 2004)
178 Open Bite

• According to a study by Larsson, after quitting the • Vestibular shield incorporating a crib
dummy sucking habit and before the eruption of
• Functional appliances
permanent teeth, children tend to suck digits. In
contrast, children with digit sucking habits con- Types of fixed habit breakers
tinued doing so, resulting in malocclusions in the
These include:
permanent dentition (Larsson, 1971). Therefore, a
dummy sucking habit is easier to stop than a thumb • Maxillary lingual arch with palatal crib
sucking habit and children who use a dummy are • Vertical crib
less likely to become thumb suckers. Therefore dum-
my sucking has been advocated in preference to digit • Combination crib
sucking according to the Guidelines for Dummy and • Hayrake appliance - spurs added to a metal crib
Digit-Sucking Habits. London: British Orthodontic placed in the anterior portion of the palate.
Society, 2001. According to recent evidence, using a
dummy may reduce the risk of sudden infant death • Bluegrass appliance (Haskell and Mink, 1991) - a
syndrome (SIDS) (Li et al., 2006). roller is positioned toward the front half of the roof
of the mouth, and patients are instructed to play
Management of digit-sucking habits with the roller bead instead of sucking their digits.
The child must want to stop the habit; otherwise, any ap- • Modified bluegrass appliance - two rollers which
proach is likely to be unsuccessful (Borrie et al., 2015). A may be of two different colours
child undergoing severe psychological trauma is unlikely to
respond to any effort toward breaking the habit, and a psy- • Quadhelix – useful in children who require max-
chologist’s input may be required. The following interven- illary expansion, and the helix also serves as a re-
tions are recommended to break the habit: minder to refrain from thumb sucking.
1. Non-physical methods • Soldered W arch - serves as a reminder appliance

as well as helpful in correcting posterior crossbite
• Explanation - Simple advice about the negative ef- caused by thumb sucking.
fect of the habit.
Summary of evidence
• Small tangible rewards can be offered daily for not
engaging in the habit. • In a systematic review, (Borrie et al., 2015) reported
that orthodontic appliances (palatal arch and pala-
• Habit reversal is categorized into five phases: Aware- tal crib) and psychological interventions (including
ness training, relaxation training, competing for re- positive and negative reinforcement) are effective at
sponse training, motivation training and generalisa- improving sucking cessation in children compared
tion training. with no treatment. The review also concluded that
2. Physical methods palatal crib were beneficial for the occlusion com-
pared with no treatment.
• Reminder therapy by using a physical barrier such
as finger bandage, foul-tasting paint on nail var- • According to Cozza (Cozza et al., 2007), quad he-
nish, thermoplastic fingerpost, cotton glove, sock, or lix/crib appliance was effective in correcting dental
thumb guard open bite in 85% of growing patients with thumb-
sucking habits and dentoskeletal open bites. Correc-
• Intra-oral appliances act as deterrent appliances; tion of the anterior open bite was associated with a
they have been influential within 10 months and clinically significant improvement in maxilloman-
should be used after 7 months. They must be fitted dibular vertical skeletal relationships.
with the full understanding and co-operation of the
child and must not compromise compliance with • According to a prospective randomised controlled
any future orthodontic treatment. trial by Leite (Leite et al., 2016), both the fixed pala-
tal crib and bonded lingual spurs are beneficial in
Types of removable habit breakers breaking sucking habits and maintaining appropri-
These include: ate tongue posture, effectively treating anterior open
bite in growing patients when of digit sucking habit
• Acrylic plate with an anterior bite plane and habit
aetiology. However, the fixed palatal crib is more
loops (act as a reminder to break the habit) along
beneficial than removable appliances or bonded lin-
with labial bow
gual spurs as it increases the stability of the dentofa-
• Hawley retainer with or without lingual spurs cial morphologic correction.
Open Bite 179

• According to a controlled clinical trial by (Insa- et al., 2016), both bonded and conventional spurs
bralde et al., 2016), both removable palatal crib and resulted in a similar increase in overbite during early
bonded spurs associated with chin cup were effective open-bite treatment. 92.5% of the children had ad-
in improving overbite; however, high-pull chin cup justed to the spurs after a week or less of treatment.
therapy alone did not give favourable effects in ante- Another trial (Slaviero et al., 2017) showed that both
rior open bite patients. fixed and removable palatal cribs are similarly effec-
tive for correcting anterior open bite, providing an
• According to a systematic review by (Koletsi et al.,
increase in overbite with dentoalveolar arch changes,
2018), there was no evidence to support bonded lin-
especially in the anterior region. A recent systematic
gual spurs over banded fixed appliances to correct
review with a meta-analysis by (Feres et al., 2017)
anterior open bite in mixed dentition children pre-
suggested that crib therapy could be regarded as an
senting with digit sucking habits.
effective treatment for anterior open bite correction
Management of mouth breathing in growing patients, with an increase in overbite of
about 3 mm. In comparison with removable palatal
Adenoidectomy or tonsillectomy should only be done for
cribs, fixed tongue cribs resulted in greater anterior
specific medical reasons (Ng et al., 2008). Evidence showed
open bite correction mainly due to greater extrusion
that surgical removal of hypertrophic tonsils or adenoids did
of maxillary incisors according to a controlled clini-
not correspond with changes in vertical dentofacial growth
cal trial by (Torres et al., 2012). However, removable
in deciduous and mixed dentition patients and did not result
palatal cribs promoted better inclination correction
in correction of anterior open bite (Lembrechts et al., 1999,
of upper and lower incisors resulting in ideal overjet
Souki et al., 2010). On the other hand, a trial showed that ad-
correction through reduction.
enotonsillectomy improved the facial growth of children with
obstructive hypertrophy, which was more evident when as- Myofunctional therapy for the treatment of AOB
sociated with rapid maxillary expansion (Pereira et al., 2012).
Orofacial myofunctional therapy in combination with orth-
Management of secondary tongue thrust odontic treatment is more effective in maintaining anterior
open bites than orthodontic treatment alone (Smithpeter and
These include:
Covell, 2010).
• Tongue guard allows spontaneous and stable correc-
1. Muscle exercises
tion of an anterior open bite in a patient with adap-
tive tongue thrust (Rodrigues de Almeida and Ursi, Different muscle training exercises described in the literature
1990). Its use must be limited to patients who have include individual practice sessions followed by homework,
reached puberty (Proffit and Mason, 1975); as 80% training exercise cycles and repetitions, holding of small
of children who have adaptive tongue thrust and an- items (such as coins or plastic spatula), or other appliances
terior open bite at 8 years of age show improvement between the lips and lip sealing exercises (Lembrechts et al.,
without therapy, indications are therefore of an an- 1999, Erbay et al., 1995a, Das and Beena, 2009, Degan and
terior open bite and an adolescent of normal dental Puppin-Rontani, 2005, Korbmacher et al., 2004). In one study
development, aged 12 and above (Burford and Noar, (Parks et al., 2007), patients were instructed to clench their
2003). teeth together as hard as possible for 15 seconds and to repeat
this process at least four times for a total of one minute; this
• Tongue spurs/palatal crib: Parker (Parker, 1971)
exercise was to be performed as often as possible throughout
used sharpened spurs soldered to upper central inci-
the day. It was concluded that masticatory muscle exercises as
sor bands to significantly improve anterior open bite
adjunctive therapy for hyperdivergent patients treated with
and posterior crossbite by modifying tongue pos-
fixed orthodontic appliances produced greater overbite in-
ture. Huang (Huang et al., 1990) demonstrated that
creases than orthodontic treatment alone. In one randomised
palatal cribs were can change tongue posture pro-
controlled study (Degan and Puppin-Rontani, 2005), differ-
ducing correction of an anterior open bite. Psycho-
ent orofacial muscle training protocols used as an adjunct
logical problems might be encountered with spurs
to traditional counselling methods for habit elimination re-
and temporary speech issues and difficulty in eating.
sulted in a more normalised resting position of the tongue
(Haryett et al., 1970, Haryett et al., 1967). Therefore,
in the anterior part of the hard palate. According to another
the clinician needs to explain the purpose of tongue
randomised controlled study (Korbmacher et al., 2004), ap-
spurs before starting treatment to motivate the pa-
pliance based orofacial muscle training therapy was able to
tient. Spurs/cribs must be worn for an additional six
significantly alter habitual mouth breathing to nasal breath-
months after achieving positive overbite, and they
ing and result in normalisation of tongue thrust swallowing
may be carried over into the retention phase. Ac-
pattern compared to conventional exercise-based myofunc-
cording to a randomised controlled trial by (Canuto
180 Open Bite

tional treatment protocol. They concluded the use of an ap- ing upward and forward mandibular rotation (Erbay et al.,
pliance was more beneficial when compared to muscle train- 1995b).
ing exercises with regard to promoting patient’s awareness
According to a comparative study by (Fränkel and Fränkel,
and compliance.
1983), function regulators along with lip-seal training led to a
2. Vertical holding appliance postural balance between the forward and backward rotating
muscles, resulting in overcoming the poor postural patterns
It is a modified transpalatal arch with an acrylic pad that relies
of the orofacial musculature and re-establishment of a com-
on tongue pressure to reduce eruption of upper first molars
petent lip seal, producing considerable changes in the soft
during growth (Wilson, 1996); however, these effects have
tissue profile and improvement of vertical components. Ac-
not been proven clinically (Wise et al., 1994, Deberardinis et
cording to a Cochrane review by Lentini-Oliveira (Lentini-
al., 2000). It can restrict further anterior bite opening result-
Oliveira et al., 2007), there is weak evidence that FR-4 with
ing from extrusion of molars during levelling and alignment
lip-seal training and removable appliances with palatal cribs
(Deberardinis et al., 2000).
combined with high-pull chin cup can correct anterior open
3. Passive posterior bite blocks bite in children. The clinical trials, however included signifi-
cant potential biases; these results must be viewed with cau-
Bite blocks are functional appliances used to open the bite
tion. According to a controlled clinical trial by (Haydar and
3–4 mm beyond the rest position. This inhibits the increase
Enacar, 1992), the FR4 appliance was mainly effective in pro-
in the height of the buccal dentoalveolar processes in grow-
ducing dentoalveolar changes for open bite closure; it did not
ing patients, preventing a downwards and backward rotation
produce any significant skeletal changes, failed to improve
of the mandible (Iscan and Sarisoy, 1997); and allows closure
the facial pattern and only camouflaged the existing vertical
of the anterior open bite due to differential eruption of the
problem.
labial segments which can erupt unhindered. The bite blocks
are usually set at a slightly elevated position vertically. The 6. Open bite bionator
stretched muscles place an intrusive force on the posterior
According to a retrospective study by (Weinbach and Smith,
teeth impeding their eruption and allowing an upward and
1992), this appliance was indicated in growing patients with
forward autorotation of the mandible (Ngan and Fields,
class 2 skeletal patterns, where the eruption of posterior teeth
1997).
would be undesirable, either due to a slight anterior open bite
It has been shown that posterior bite blocks modify the verti- or a divergent skeletal pattern, rather than for severe open
cal skeletal pattern effectively (McNamara, 1977). Modifica- bite cases.
tions in their design have included spring-loaded bite blocks
7. Modifications of twin block appliance
and use of repelling magnets embedded in the acrylic of bite
blocks (Noar et al., 1996). Cemented magnets are twice as ef- These include:
fective as the removable spring-loaded appliance (Kuster and
• The lower appliance is extended distally to the molar
Ingervall, 1992). Using bite blocks in conjunction with a high
region with clasps on lower first molars, and occlusal
pull headgear may increase their effectiveness (Galletto et al.,
rests on second molars to prevent their eruption; up-
1990).
per appliance may incorporate a palatal spinner to
4. Spring-loaded bite block control tongue thrust, palatal crib to keep the tongue
away from anterior teeth, tongue guard, labial bow
It has helical springs placed both lingually and buccally in
to retract upper incisors and midline expansion
the region between the first premolar and the last molar. The
screw to widen the upper arch to accommodate the
ends of the springs are lodged occlusally in the molar regions
lower arch.
of the acrylic part of the device. The upper and lower acrylic
occlusal blocks are connected by palatal and lingual wires, • Twin Block with the upper block designed like a
which are activated to a force of 450 grams bilaterally. Pa- ‘maxillary intrusion splint’ along with extraoral trac-
tients are instructed to wear the appliance for approximately tion tubes for high pull headgear can be used to cor-
16 hours daily (Işcan et al., 1992). rect the anteroposterior discrepancy while control-
ling the vertical dimension if an anterior open bite is
5. Functional regulator appliance (Fr. IV)
associated with Class 2 skeletal pattern (Parkin et al.,
It is thought to be useful where the open bite is partly due to 2001).
faulty postural activity of the orofacial musculature (Fränkel
• Intra-oral elastics can accelerate bite closure as an
and Fränkel, 1983). It works by allowing vertical eruption of
alternative to high pull extraoral traction. This rein-
upper and lower incisors, retraction of the maxillary incisors.
forces the intrusive effect of bite blocks.
It can change the usual downward and backward rotation of
the mandible in patients with skeletal open bite by encourag- • Twin block with occlusal screws placed in the up-
Open Bite 181

per block can be used for progressive mandibular • Maxillary Intrusion Splint and Lower Traction Plate
advancement to ensure that the patient with vertical (CONCORDE)
growth pattern can maintain a protrusive position
Extraoral appliance for management of AOB
comfortably to allow their weak muscles to adapt
more gradually to mandibular advancement. (Ge- 1. Vertical pull chin cup.
serick et al., 2006, Carmichael et al., 1999)
It is used as a functional orthopaedic appliance for the treat-
• Trimming of the upper occlusal block should be ment of skeletal open bite in an attempt to limit vertical jaw
avoided to prevent the eruption of lower molars as growth. It delivers a force of 450-500 g per side, with the force
vertical development is not needed / undesired, in- vector passing 45 degrees above the occlusal plane through
stead of to continue to apply a desirable intrusive the anterior and inferior region of the mandibular corpus
force to the posterior teeth. (Clark, 2010) approximately 3 cm from the outer canthus of the eye, and
it should be used for 14-16 hours per day (Pearson, 1973).
• Thick Twin block appliance: The ramps are 5 to 8
Vertical chin cup therapy effectively reduced the mandibular
mm thick in the premolar region, opening the bite
plane angle and facial height during treatment and can be a
beyond the freeway space and increasing tension in
helpful treatment procedure in some backwards-rotating pa-
masseter muscle, which restricts maxillary posterior
tients. Mandibular autorotation was attributed to a reduction
teeth’ eruption and produces relative relative intru-
in the ‘wedging’ effect by premolar extraction, retardation of
sion of the posterior aspect of the maxilla in growing
the eruption of posterior teeth and redirection of condylar
patients. This is known as the bite-block effect and
growth (Pearson, 1978, Pearson, 1986).
provides excellent vertical control.
Vertical chin cup therapy resulted in some intrusion of man-
Combined myofunctional and extraoral appliance combi-
dibular molars in a group of growing patients with open bites
nation therapy
compared to the control group (Işcan et al., 2002). The dis-
These include: advantages of chin cup therapy include poor compliance and
the possibility of condylar damage (Burford and Noar, 2003).
• Combined activator-high pull headgear appliances
have been recommended to reduce vertical and sag- In a randomised clinical trial (Pedrin et al., 2006), it was
ittal maxillary displacement, obtain auto-rotations, found that the association of high-pull chin cup therapy with
and increase the mandible’s forward displacement in a removable appliance and palatal crib provided no positive
Class 2 high-angle cases (Teuscher, 1978, Teuscher, skeletal influence on the vertical facial pattern of patients
1986). treated for an open bite in the mixed dentition. According to
a prospective randomised study (Torres et al., 2006), using a
• Van Beek appliance is a modified Harvold activa-
removable appliance with palatal cribs associated with high
tor with two arms for extraoral traction, requiring a
pull chin cup therapy, there were no significant differences
minimum force of 300 grams per side for 12 hours.
in the level of molar eruption or lower anterior face height,
• Teuscher activator is similar to Van Beek, but head- suggesting that the vertical control expected from the chin
gear is attached to the posterior segment of the ac- cup therapy did not occur. Dentoalveolar changes at the an-
tivator and torque springs are positioned on upper terior region of the dental arches (with statistically significant
incisors. extrusion, retrusion, and lingual tipping of the maxillary and
mandibular incisors) rather than soft tissue changes were
• Buccal intrusion splint (BIS) is used to treat skeletal
mainly responsible for the closure of the anterior open bite in
anterior open bites by the intrusion of the upper
patients treated in the mixed dentition.
buccal segment teeth.
2. High-pull headgear
• Maxillary Intrusion Splint (MIS) consists of high
pull headgear attached to a full-coverage maxillary High pull headgear can be worn 14 hours per day, delivering
occlusal splint. The palatal soft tissues have been 500 g of force to maxillary molar teeth of growing children
blocked out, so the intrusive force transmitted to the with skeletal class 2 base relationship to control and limit
removable appliance is transmitted directly to the posterior vertical growth of maxilla, inhibit eruption of pos-
teeth and is not resisted by the vault of the palate. terior teeth, minimising clockwise rotation and redirecting
According to (Caldwell et al., 1984), it resulted in mandibular growth in a more anterior rather than the verti-
the superior and distal displacement of the maxilla, cal direction (Watson, 1972, Kuhn, 1968, Poulton, 1967). Its
reduction in the SNA angle, clockwise rotation of effects are based on the assumption that overdevelopment of
the palatal plane, and relative intrusion of the upper the posterior maxilla is responsible for the open-bite defor-
molars among patients with Class 2 Division 1 mal- mity (Epker and Fish, 1977). Different options available are
occlusion and maxillary dentoalveolar protrusion. as follows:
182 Open Bite

• Headgear can be applied directly to the upper molar it may be effective in hyperdivergent cases with
bands of a fixed appliance - sufficient to close minor moderate crowding, but it is controversial in cases
anterior open bites. of severe open bite (Cangialosi, 1984). Molar extrac-
tions may reduce the magnitude of the open bite by
• Headgear can be used in conjunction with a func-
forwarding mandibular rotation. Still, it does not al-
tional appliance to try and correct an increased
ter the physiological rest position of the mandible,
overjet when there is a reduced overbite and a verti-
so the total facial height remains the same (Nahoum,
cal growth pattern.
1977). Similarly, other researchers believe extraction
• Headgear is used along with upper removable ap- therapy does not reduce the lower facial height of
pliance with posterior cappings such as a maxillary patients with an open bite who have supra-eruption
intrusion splint or buccal intrusion splint. of the lower molars. (Kim et al., 2000) (Jenner and
Fitzpatrick, 1985).
• High pull headgear along with transpalatal arch giv-
en in Class 2 patients to intrude upper first molars • Bracket set up: This includes reduced canine tipping
and prevent the dropping of palatal cusps (Firouz et and gingival placement of the brackets of the ante-
al., 1992). rior teeth.
Treatment principles in the management of AOB using • Tongue tamer or palatal crib: According to a ran-
fixed appliances domised clinical study by (Leite et al., 2016), both
the fixed palatal crib and bonded lingual spurs are
Arat (Arat and Iseri, 1992) compared the effectiveness of the
simple and effective for the treatment of anterior
Begg technique, Edgewise technique, and functional appli-
open bite in mixed dentition, with fixed palatal cribs
ances for the treatment of skeletal open bite. Fixed appliance
being favoured.
therapy increased the upper and lower posterior dentoalveo-
lar height, marked backward rotation of the mandible, and • Quad-helix/crib appliance: According to a con-
increased anterior facial height. Some treatment principles trolled clinical trial by (Mucedero et al., 2013), quad-
are as follows: helix/crib appliance led to successful outcomes in
about 93% of the patients & correction of dentoskel-
• Banding of second molars should be avoided be-
etal open bite was associated with a clinically signifi-
cause they tend to extrude when engaged on the
cant downward rotation of the palatal plane.
archwire. If second molars are banded, they should
be banded or bonded with the molar tubes in the • Vertical intermaxillary elastics: Vertical intermaxil-
occlusal third of the clinical crown, or the archwire lary elastics can be used to extrude the anterior teeth
should be stepped gingivally to avoid extrusion of in patients where the anterior open bite is related
the terminal molar on the appliance (Pearson, 1996). to a digit-sucking habit that has prevented the inci-
sors’ eruption. Elastics are not recommended if the
• Any procedure that would promote an increase in
aetiology is primarily skeletal because the incisors
facial height or extrusion of posterior teeth must be
are already maximally erupted. Any orthodontic
avoided to prevent worsening of an anterior open
treatment aimed at extruding them would be aes-
bite; therefore, Class 2 and Class 3 elastics and the
thetically inappropriate and unstable. Elastic may be
distal movement of teeth using headgear are contra-
combined with a transpalatal arch (TPA) and high-
indicated (unless intrusion is also planned).
pull headgear to restrict vertical development of the
• Extraction therapy: If extractions are indicated in maxillary molar teeth.
high angle cases (due to caries, gross premature
•
Kim mechanics (Multiloop Edgewise Archwire
contact etc.), extractions more posterior in the arch
Technique)
can be helpful as it reduces the posterior face height
by the forward movement of terminal molars, caus- Kim mechanics
ing a reduction in maxillo-mandibular plane angle
This technique uses multi-loop gable-bend edgewise arch-
(Mizrahi, 1978) (Aras, 2002). Extraction therapy can
wires made from rectangular 0.016 × 0.022 stainless steel
result in a significant increase in the lower posteri-
archwires with a series of vertical loops bent into them for
or face height in moderately steep cases (Pearson,
flexibility with divergent curves of Spee (increased curve of
1973) & mesialization of posterior teeth following
Spee in the maxillary arch and a reverse curve of Spee in the
extractions can achieve intrusion of molars (Jacob-
mandibular arch) combined with heavy anterior elastics to
son, 1986). Extraction of premolars or molars has
achieve molar intrusion and simultaneous incisor extrusion
been recommended to “close the wedge” and to re-
to close the bite anteriorly (Kim, 1987).
duce the vertical dimensions (de Freitas et al., 2004);
Open Bite 183

Kim recommended a 0.018” slot and standard edgewise bite malocclusion (Umemori et al., 1999).
brackets, but the use of 0.022” straight-wire appliance sys-
• Miniscrews can bring about the absolute intrusion
tems have also been used with this technique. Five L-loops
of posterior teeth, which may help to increase the
are placed on each side of the archwire, starting between the
overbite (Kravitz et al., 2007, Cousley, 2014). Minis-
lateral incisors and canines to the first and second molars.
crew has been reported to provide skeletal anchorage
The vertical dimensions of the loops should be 2-3 mm, and
to intrude buccal segments in patients with hyperdi-
the horizontal dimensions should be 5 mm except in the mo-
vergent growth patterns by reducing the posterior
lar region where it is increased to 8 mm. Tip backs of 3 to
dental height, resulting in autorotation of mandible
5 degrees are placed on each loop. 3/16” heavy elastics are
in a closing counterclockwise direction. Closure of
placed vertically between the most anterior loops in the max-
maxilla-mandibular plane angle and reduction of
illa and mandible.
anterior facial height occurs without the need for
Active forces in the archwire are transferred to the posterior surgical intervention (Park et al., 2004); this rotation
buccal segments resulting in the posterior intrusion. Mesial is also suggested by a systematic review which may
tipping of the molars is commonly seen in skeletal open bite lead to an improvement in facial profile, especially in
resulting in rotation of the occlusal plane; the posterior teeth hyperdivergent patients (Alsafadi et al., 2016).
are distally uprighted using this technique by placing a flat
• Miniscrew implants must be placed distal to the
0.016” x 0.022” archwire once the terminal molars are out of
centre of resistance of the whole dentition (premolar
contact and no further reduction of the anterior open bite
region) since the resultant posterior intrusive force
occurs while continuing the anterior elastics. Distal upright-
produces a clockwise rotation of the maxillary den-
ing of buccal dentition is facilitated by removing the terminal
tition and a counterclockwise rotation of the man-
molars, as this removes occlusal contacts closer to the ful-
dibular dentition, which contributes to the closure
crum of the temporomandibular joint, allowing the mandible
of the anterior open bite (Park et al., 2006).
to hinge upward forward.
• The magnitude of the mandibular autorotation after
Extracting the second molars could minimise resistance to
molar intrusion depends on several factors, includ-
uprighting the posterior teeth in adolescents who have well-
ing the amount of intrusive force, duration of intru-
shaped and well-positioned third molars.
sion, and placement of intrusive force in the upper
This technique minimally affects the skeletal pattern and has or lower arch. It is believed that 1 mm of intrusive
limited usefulness for patients with adequate or excessive vertical movement of the molars would result in
dentoalveolar height before treatment. about 2 mm closure of anterior open bite by man-
dibular counterclockwise rotation (Scheffler et al.,
Treatment changes occur mainly by a dentoalveolar compen-
2014).
sation mechanism, which causes retraction and extrusion of
the anterior teeth, alteration of the occlusal plane and distal • Molars can be intruded approximately 2-4 mm us-
uprighting of posterior teeth (Küçükkeleş et al., 1999, Chang ing skeletal anchorage, with better results in the
and Moon, 1999). maxilla compared to mandible (Scheffler et al., 2014,
Deguchi et al., 2011, Baek et al., 2010, Akan et al.,
Modified Kim mechanics
2013). This can be attributed to the thicker corti-
Nickel-titanium wires can be used rather than multi-looped cal bone in mandible that may resist intrusive forces
rectangular archwires, achieving similar flexibility to multi more than the maxilla (Deguchi et al., 2011).
looped stainless steel archwires and without the requirement
• Molar intrusion using TADs and elastomeric chains
of bending loops (Küçükkeleş et al., 1999). The wires are
attached to miniscrews can apply a force of 150–200
modified by placing an accentuated curve of Spee in the max-
g per tooth on each side (Buschang et al., 2011, Xun
illary arch and a reverse curve of Spee in the mandibular arch
et al., 2007). Miniplates can apply 400 g of force per
combined with heavy anterior vertical elastics with crimpable
segment for posterior tooth intrusion (Akan et al.,
hooks. This effectively overcomes the extrusive forces placed
2013, Erverdi et al., 2007).
on the anterior teeth and causes their intrusion (Enacar et
al., 1996). Treatment considerations of AOB treated with molar in-
trusion
Molar intrusion using skeletal anchorage
These include:
These include:
• Consider the skeletal relationship, including the
• Titanium miniplates temporarily implanted in the
vertical, transverse, and sagittal relations. Skeletal
maxilla or mandible can provide temporary skeletal
Class 1 or mild skeletal Class 2 jaw relationships
anchorage for molar intrusion in managing the open
184 Open Bite

with skeletal open bite and extended anterior facial face cases (Antoszewska et al., 2009, Miyawaki et al.,
height can be treated by the intrusion of posterior 2003). Various options for insertion sites of mini-
teeth as a closing counterclockwise rotation of the implants in AOB cases are available, including:
mandible occurs with a shortening of the anterior
a) Buccally positioned TADs apply intrusive vertical force to
facial height and a correction of the open bite. Ac-
the molars and a TPA in the maxilla or a lingual arch in the
cording to Sugawara 2002 (Sugawara et al., 2002),
mandible to prevent distortion of the arch form and buccal
miniscrew supported molar intrusion resulted in a
tipping of the posterior teeth. Tongue pressure on the maxil-
significant reduction in anterior lower facial height,
lary TPA may contribute to molar intrusion. It must be re-
mandibular plane angle, and ANB difference along
lieved from the palatal mucosa, approximately the distance
with a significant increase in overbite and Wits ap-
that the molars are expected to be intruded (Sherwood, 2007).
praisal. In the case of skeletal Class 3 open bite, the
counterclockwise rotation caused by the intrusion b) For TADs located in the palate, the torque and bucco-
of posterior teeth worsens the Class 3 discrepancy, palatal position of the molars being intruded must be moni-
despite the correction of open bite, making orthog- tored since it is difficult to obtain a vector sum that passes
nathic surgery more likely to be required. through the centre of resistance due to the anatomy of the
palatal and buccal alveolar bone. A buccal force from another
• Consider facial esthetics such as incisor exposure
buccal screw can be combined to counteract the palatal mo-
at rest and smile before starting treatment. Patients
ment (Lee et al., 2004). Cousley performed maxillary molar
with insufficient incisor exposure should not be
intrusion by bilateral mini-implants inserted in the palatal
treated by the molar intrusion, as incisor extrusion
alveolus and a customised TPA for both transverse arch con-
is more suitable for open bite correction. Clockwise
trol and the application of direct traction (Cousley, 2010). For
rotation of the whole maxillary arch can occur dur-
intrusion of a single molar tooth, the force could be applied
ing molar intrusion if the entire arch is bonded with
from a cantilever attached directly to the miniscrew in com-
fixed appliances; this can be minimised with either
bination with a TPA to counteract third-order side effects
sectional arch mechanics or by adding an exagger-
(Uribe et al., 2013).
ated curve of Spee to the maxillary archwire if extru-
sion of upper incisors is contraindicated (Park et al., Rapid molar intrusion device (RMI)
2006, Erverdi et al., 2004).
RMI was first proposed by Carano (Carano and Machata,
• Careful control of the first, second, and third-order 2002) as a non-compliance option for treating anterior open
relationships of the intruded molars is essential for bite. It is composed of two elastic modules secured on the
a successful outcome during the active intrusion first molars with L-shaped pins; the straight terminal end at-
phase. taches into a maxillary molar tube, and the angulated termi-
nal end attaches to a mandibular tube. The flexed modules
• The periodontal condition must be considered since
deliver an immediate intrusive force of 800 g on each side
intrusive forces might affect the periodontal health
when the patient closes their mouth; this force level decays
of the intruded molars. Regarding the intrusion of a
to 450 g by the end of the 1st week and 250 g by the second
molar with periodontal disease, (Melsen et al., 1988)
week. This appliance is always placed with a TPA in the upper
reported that periodontal tissue recovers by new at-
arch and a lingual arch in the lower arch because the intrusive
tachment through intrusion. In contrast, Vanarsdall
forces on the labial side of the molars generate moments that
(Vanarsdall, 1995) suggested extrusion rather than
tip the crowns buccally.
intrusion for the health of the periodontal tissue as
bone deposition occurs with tension rather than Advantages and disadvantages of RMI
pressure. In patients with mild periodontal disease,
These include:
periodontal treatment is needed before the orth-
odontic treatment, and periodic periodontal man- • Significant intrusion of upper and lower first molars
agement and radiographs should be taken during in growing patients and adults.
treatment. If the periodontal condition is not suit- • It can also intrude on the first and second molars if
able for molar intrusion, surgical intervention is re- attached together.
quired to correct open bite.
• Both the upper and lower molars are intruded si-
• Assessment of bone quality, local root anatomy, ac- multaneously, so it cannot be used for the intrusion
cessibility at insertion site. Maxillary buccal mini- of molars in one arch (Carano et al., 2005a, Carano
implants have been less stable in high angle cases et al., 2005b).
than normal/low angle ones, which is most likely
linked to the thinner maxillary cortical plate in long Repelling magnets for the treatment of OAB
Open Bite 185

Active vertical corrector introduced by (Dellinger, 1986) is rotation of the mandible to close the anterior open
a fixed or removable appliance developed for the intrusion bite. The anterior segment is repositioned vertically
of posterior teeth in the maxilla and mandible by recipro- to obtain the ideal maxillary incisor exposure in re-
cal forces. It consists of two posterior occlusal splints with lation to the upper lip.
samarium cobalt magnets incorporated over the occlusal re-
• Isolated mandibular surgery: Anterior rotation of
gion of the teeth planned to be intruded, generating between
the distal segment of the mandible following a bi-
600 and 650 grams of force per module. Kalra (Kalra et al.,
lateral sagittal split osteotomy may be used to close
1989) have suggested that magnets may be beneficial in treat-
some mild anterior open bites up to 4 mm, in the
ment anterior open bites by:
absence of excessive inclination occlusal plane
• Intruding upper and lower posterior teeth and al- (Bloomquist and Joondeph, 2016). According to
lowing mandibular autorotation in growing patients. (Bisase et al., 2010), mandibular sagittal split oste-
otomy with rigid internal fixation was the procedure
• Distracting the condyle downwards and forwards
of choice to correct anterior open bite in patients
allows compensatory condylar growth which would
with short mandibular ramus and normal condyles
also promote favourable mandibular autorotation.
absence of ongoing resorption and a well-positioned
A randomised clinical trial (Kiliaridis et al., 1990) compared maxilla (no posterior maxillary excess).
the effects of samarium cobalt repelling magnets incorpo-
Factors contributing to skeletal relapse
rated into acrylic splints versus acrylic bite-blocks to correct
anterior open bite. Both produced a positive response in the Factors contributing to skeletal relapse after combined orth-
dental and skeletal vertical relationships in growing indi- odontic and orthognathic surgical approach:
viduals by causing intrusion of posterior teeth with intrusive
• Type of osteotomy.
forces generated by the masticatory muscles, resulting in a
decrease or elimination of anterior open bite. • Type of skeletal fixation - rigid internal fixation pro-
vides better stability compared to intraosseous wire
Orthognathic option for management of skeletal AOB
techniques. (Brammer et al., 1980, Hiranaka and
Orthognathic surgery for treatment of skeletal AOB is indi- Kelly, 1987, Hoppenreijs et al., 1997).
cated in (Greenlee et al., 2011):
• Neuromuscular influences on the repositioned jaws
• Non-growing patients. (Reyneke and Ferretti, 2007).
• Esthetic need. Adjunctive procedures
• Severe open bite and extreme vertical measure- These include:
ments are greater than two standard deviations from
• Glossectomy - It effectiveness in closing anterior or
normal.
posterior open bite problems has not been substanti-
• Skeletal problems in multiple planes of space. ated.
Surgical options to correct skeletal AOB are (Naini and Gill, • Surgical procedures to improve the patency of the
2017): airway.
• Le Fort 1 osteotomy with differential posterior max- • Occlusal adjustments (Janson et al., 2008).
illary impaction: Rotation of the maxillary occlusal
• Corticotomy assisted molar intrusion (Akay et al.,
plane around the transverse axis with differential
2009).
posterior impaction allows forward autorotation of
the mandible to close an anterior open bite. Orth- Stability of AOB treatment
odontic preparation requires proclination of the
Studies of long term results for orthodontic treatment of
maxillary incisors, as posterior surgical impaction
open bite by (Lopez-Gavito et al., 1985) and surgically treated
produces relative retroclination of the maxillary in-
cases by (Denison et al., 1989) indicate that relapse rates can
cisors.
range from 35% to 42.9%. A slight increase in overbite may
• Segmental impaction of the posterior maxilla: Verti- occur during the post retention phase, up to 15 years after
cal segment of the maxilla is cut either distal to the removing appliance (Zuroff et al., 2010). Approximately 80%
canines or distal to the lateral incisors following Le of anterior open-bite subjects will maintain positive overlap
Fort I osteotomy. After preoperative independent after treatment, whether with orthodontics or a combination
levelling and alignment, anterior and posterior seg- of orthodontic-surgical therapy (Huang, 2002).
ments are moved separately. The posterior segment
• Predictors: Overbite depth indicator (Dung and
is repositioned superiorly, allowing forward auto-
186 Open Bite

Smith, 1988) and the extent of an anterior open bite treatments regardless of the type of surgery. Den-
(Kim, 1974) at the start of treatment were the best tally, relapse was observed by an opening of the bite,
predictors of success. According to a comparative which was more commonly observed after Le Fort
study (Lopez-Gavito et al., 1985), neither the mag- I osteotomy than bimaxillary surgery. Skeletally, re-
nitude of pretreatment open bite, mandibular plane lapse was depicted by increased mandibular plane
angle, nor any other single parameter of dentofacial and intermaxillary angles during long-term follow-
form proved to be a reliable predictor of post-treat- up, which was more commonly seen after bimaxil-
ment stability. lary surgery than Le Fort I osteotomy.
• Type of treatment: Orthodontic therapies appear Causes of relapse of treated AOB cases
to have slightly lower treatment success but better
These include:
stability than the surgical therapy (Huang, 2002).
More than 35% of orthodontically treated open-bite • Unfavourable growth patterns such as posterior
patients demonstrated a post retention open bite of mandibular growth rotation & continuation of max-
3 mm or more, according to a longitudinal study by illary vertical growth after completion of orthodon-
(Lopez-Gavito et al., 1985). According to a meta- tic treatment (Burford and Noar, 2003).
analysis (Greenlee et al., 2011), the stability with
• Soft-tissue factors such as an unfavourable tongue
both surgical and non-surgical treatment modalities
posture or size, orofacial musculature & respiratory
of AOB appeared to be greater than approximately
problems (Huang, 2002) .
75%. According to a retrospective study by (Swin-
nen et al., 2001), open bite patients treated with Le • Resumption of a digit-sucking habit.
Fort I impaction or extrusion, with or without an ad- • Inappropriate orthodontic tooth movement, such
ditional bilateral sagittal split osteotomy, show good as excessive incisors extrusion when previously
maxillary stability one year after surgery. However, reached maximum vertical eruption.
the canting of the palatal plane relapsed completely
within the first year after surgery. • Surgery has increased the posterior face height; for
example, if a mandibular procedure is used in isola-
• Extraction therapy: A systematic review (Medeiros tion to close an anterior open bite.
et al., 2012) showed that orthodontic treatment with
extractions seemed to be more stable than non-ex- Retention of treated AOB cases
traction, single-jaw surgery was more stable com- These include:
pared with bimaxillary surgery. Greater stability of
open bite correction is achieved when orthodontic • Prolonged retention with fixed or removable retain-
treatment is carried out with extractions compared ers is advisable during an active growing period.
to non-extraction treatment (Janson et al., 2006, • Intrusion or prevention of eruption of posterior
Chang and Moon, 1999). maxillary teeth should be continued until growth
• Miniscrews: The tendency of relapse ranges between ceases (Lawry et al., 1990).
20% and 30% when using TADs for molar intrusion • Treatment results must be maintained to prevent la-
& the relapse predominantly occurs during the first bial flaring of the incisors (Kassir and Saade, 2017).
year of retention (Deguchi et al., 2011, Sugawara et
al., 2002, Baek et al., 2010, Sakai et al., 2008) Methods for retention
• Multiloop edgewise archwire therapy: The open bite These include:

correction obtained by the multiloop edgewise arch- • High-pull headgear or vertical chin cup applied to
wire therapy was very stable, with less than 0.5 mm the upper molars and a standard removable retainer.
of relapse occurring during the 2-year follow-up pe-
riod. (Kim et al., 2000) • Retainer with passive posterior bite blocks to place
intrusive forces on posterior teeth.
• Type of teeth movement: Extrusion of anterior teeth
to close an anterior open bite is considered less sta- • Retainers with occlusal coverage prevent further
ble than posterior intrusive mechanics, especially molar eruption in patients with remaining growth.
in cases with an excessive vertical height of anterior • Continued use of open bite activator or a bionator
maxilla (Ellis and McNamara, 1984). On the other with bite blocks between posterior teeth.
hand, a systematic review (Solano-Hernández et
al., 2013) showed that vertical relapse was seen in • Daytime wrap around retainer with modified con-
several patients after combined orthodontic surgical tour engaging the cementoenamel junction to coun-
Open Bite 187

teract the intrusive relapse of anterior teeth, along These include:
with a different appliance incorporating a tongue
• Interposition of the tongue between teeth, interfer-
crib for nighttime retention.
ing with eruption
• Tongue crib or lingual spurs during or after treat-
• Disturbances in eruption (for example, ankylosis)
ment may enhance stability in patients where abnor-
mal tongue posture and aberrant function have been • Primary failure of eruption - familial cases have
contributory factors (Huang et al., 1990, de Cuebas, been reported (Brady, 1990, Ireland, 1991)
1997, Justus, 2001).
• Primary failure of alveolar process development
• Fixed modified Nance-Hyrake appliance can also (Capon, 1944, Kurol, 1981)
train the tongue in cases of aberrant tongue position
• Trauma
or function.
•
Hemimandibular hyperplasia where the vertical
• Lip and tongue muscle exercises have been recom-
compensation is insufficient
mended once a day, supervised by a speech and lan-
guage therapist once a week. Treatment of posterior open bite
• Miniscrews used in the mandible can be kept longer These include:
during the initial phase of the retention (Deguchi et • Habit breaker in the posterior region
al., 2011).
• Restorative correction with composite build-up or
• Overcorrection has been recommended to compen- Onlay / crown
sate for any relapse after molar intrusion using TADs
(Sakai et al., 2008). •
Orthodontic extrusion with fixed appliances or
TADs
• Retainer covering the occlusal surfaces of the mo-
lars with elastics to the buccal TADs (Scheffler et al., • Segmental dentoalveolar osteotomy
2014) • Segmental maxillary or mandibular surgery
Difficulty associated with the treatment of AOB
Exam night review
These include (Burford and Noar, 2003) (Sandler et al., 2011):
Anterior open bite (AOB)
• Tendency for posterior growth rotation worsens the
Class 2 malocclusion and makes the use of function- AOB is defined as a vertical discrepancy with no contact
al appliances challenging. between anterior teeth in centric relation or lack of verti-
cal overlap of the upper incisors’ incisal third of the lower
• Majority of the orthodontic treatment mechanics incisor crowns when the posterior teeth are in occlusion
are extrusive in nature which worsens the open bite. (Houston et al., 1992).
• Poor compliance to prolonged retention methods Classification of AOB
results in poor stability.
• Based on aetiology: developmental or acquired (Shi-
• Maxillary extraction spaces may be lost quickly due ra, 1961)
to:
• Based on site (anterior or lateral) and pattern (alant-
a) Thin cortices and trabecular bone of the maxilla provide ing or angulated) (Thoma, 1943)
less resistance to movement than the mandible’s thick corti-
ces and denser trabeculae. •
Based on severity and extent of involvement,
(Worms et al., 1971)
b) Masticatory muscles provide greater restriction to pos-
terior mandibular teeth movement than posterior maxillary • Based on the morphology of the skeletal pattern
teeth. (Kim, 1974), which include:
Posterior open bite • Based on aetiological and skeletal considerations,

(Richardson, 1981)
It is defined as the failure of several teeth in either or both
opposing buccal segments to reach occlusion, although there Incidence of AOB
is incisor contact. Autosomal dominant inheritance has been • Prevalence increases to 36.3% when the anterior
reported (Bosker et al., 1978). open bite is associated with sucking habits in the
Causes of posterior open bite mixed dentition (Cozza et al., 2005)
188 Open Bite

• AOB is more common in Africans and Africa-Ca- • Combined myofunctional and extraoral appliance
ribbeans with a prevalence of 5% (Noar and Portnoy, combination therapy
1991)
Fixed appliances
Bjork’s structural signs of backward/posterior mandibular
• Extraction therapy
growth rotation (Björk, 1969)
• Bracket set up
• A backward inclination of the condylar head
• Wire bending to allow incisor extrusion
• The curvature of the mandibular canal is flat/straight
• Tongue tamer or palatal crib
• Prominent antegonial notch
• Quad-helix/crib appliance
• The mandibular symphysis is inclined backwards
and the chin is flattened and receding. • Segmented arch mechanics
• The interincisal, inter-premolar and intermolar an- • Vertical intermaxillary elastics
gles are all decreased
•
Kim mechanics (Multiloop Edgewise Archwire
• The lower anterior face height is increased, and Technique).
there is an anterior open bite
• Modified Kim mechanics
Aetiology of AOB
• Molar intrusion with skeletal Anchorage
• Skeletal factors
• Rapid Molar Intrusion device (RMI)
• Environmental factors
• Repelling Magnets
• Local dental factors
Orthognathic surgery
• Pathological factors
1. Le Fort 1 osteotomy with differential posterior maxillary
• Iatrogenic factors impaction
• Soft tissue factors 2. Segmental impaction of the posterior maxilla
Management of digit-sucking habits 3. Isolated mandibular surgery
1. Psychological counselling Adjunctive procedures
2. Non-physical methods • Glossectomies
• Explanation • Surgical procedures →improve patency of airway.
• Reward • Occlusal adjustments.
• Habit reversal • Corticotomy assisted molar intrusion.
3. Physical methods Causes of relapse
Myofunctional therapy for the treatment of AOB 1. Unfavorable growth patterns
• Muscle exercises (Lembrechts et al., 1999, Erbay et 2. Unfavorable tongue posture or size, orofacial muscula-
al., 1995a, Das and Beena, 2009, Degan and Puppin- ture & respiratory problems.
Rontani, 2005, Korbmacher et al., 2004).
3. Resumption of a digit-sucking habit.
• Vertical holding appliance (Wilson, 1996)
4. Inappropriate orthodontic tooth movement
• Passive posterior bite blocks (Iscan and Sarisoy,
5. Wrong orthognathic Surgery planning
1997)
Retention
• Spring-loaded bite block (Işcan et al., 1992).
• Prolonged retention with fixed/removable retainers
• Functional regulator appliance (Fr. IV) (Fränkel and
→in active growth.
Fränkel, 1983).
• Intrusion or prevention of eruption of posterior
• Open bite bionator (Weinbach and Smith, 1992)
maxillary teeth →until growth ceases.
• Modifications of twin block appliance
• Prevent labial flaring of incisors
Open Bite 189

References: BLOOMQUIST, D. & JOONDEPH, D. 2016. Surgical treatment
of anterior open bite with mandibular osteotomies. Orthognathic
ADAIR, S. M. 2003. Pacifier use in children: a review of recent
Surgery: Principles, Planning and Practice, 521-529.
literature. Pediatr Dent, 25, 449-58.
BORRIE, F. R., BEARN, D. R., INNES, N. P. & IHEOZOR-EJIO-
AKAN, S., KOCADERELI, I., AKTAS, A. & TAŞAR, F. 2013. Ef-
FOR, Z. 2015. Interventions for the cessation of non-nutritive suck-
fects of maxillary molar intrusion with zygomatic anchorage on the
ing habits in children. Cochrane Database Syst Rev, Cd008694.
stomatognathic system in anterior open bite patients. Eur J Orthod,
35, 93-102. BOSKER, H., TEN KATE, L. P. & NIJENHUIS, L. E. 1978. Familial
reinclusion of permanent molars. Clin Genet, 13, 314-20.
AKAY, M. C., ARAS, A., GUNBAY, T., AKYALCIN, S. & KOYUN-
CUE, B. O. 2009. Enhanced effect of combined treatment with BOWDEN, B. D. 1966. The effects of digital and dummy sucking
corticotomy and skeletal anchorage in open bite correction. J Oral on arch widths, overbite, and overjet: a longitudinal study. Aust
Maxillofac Surg, 67, 563-9. Dent J, 11, 396-404.
ALI, N. J., PITSON, D. J. & STRADLING, J. R. 1993. Snoring, sleep BRADY, J. 1990. Familial primary failure of eruption of permanent
disturbance, and behaviour in 4-5 year olds. Arch Dis Child, 68, teeth. Br J Orthod, 17, 109-13.
360-6.
BRAMMER, J., FINN, R., BELL, W. H., SINN, D., REISCH, J. &
ALSAFADI, A. S., ALABDULLAH, M. M., SALTAJI, H., ABDO, DANA, K. 1980. Stability after bimaxillary surgery to correct verti-
A. & YOUSSEF, M. 2016. Effect of molar intrusion with temporary cal maxillary excess and mandibular deficiency. J Oral Surg, 38,
anchorage devices in patients with anterior open bite: a systematic 664-70.
review. Prog Orthod, 17, 9.
BRENCHLEY, M. L. 1992. ‘Is digit sucking of significance?’. Br
ANTOSZEWSKA, J., PAPADOPOULOS, M. A., PARK, H. S. & Dent J, 172, 269.
LUDWIG, B. 2009. Five-year experience with orthodontic minis-
BURFORD, D. & NOAR, J. H. 2003. The causes, diagnosis and
crew implants: a retrospective investigation of factors influencing
treatment of anterior open bite. Dent Update, 30, 235-41.
success rates. Am J Orthod Dentofacial Orthop, 136, 158.e1-10;
discussion 158-9. BUSCHANG, P. H., CARRILLO, R. & ROSSOUW, P. E. 2011.
Orthopedic correction of growing hyperdivergent, retrognathic pa-
ARAS, A. 2002. Vertical changes following orthodontic extraction
tients with miniscrew implants. J Oral Maxillofac Surg, 69, 754-62.
treatment in skeletal open bite subjects. Eur J Orthod, 24, 407-16.
CADDEN, S. W. 2004. The influence of oral habits on the develop-
ARAT, M. & ISERI, H. 1992. Orthodontic and orthopaedic ap-
ing dentition and their treatment: clinical and historical perspec-
proach in the treatment of skeletal open bite. Eur J Orthod, 14,
tives, (2003). Oxford University Press.
207-15.
CALDWELL, S. F., HYMAS, T. A. & TIMM, T. A. 1984. Maxil-
BAEK, M. S., CHOI, Y. J., YU, H. S., LEE, K. J., KWAK, J. & PARK,
lary traction splint: a cephalometric evaluation. Am J Orthod, 85,
Y. C. 2010. Long-term stability of anterior open-bite treatment by
376-84.
intrusion of maxillary posterior teeth. Am J Orthod Dentofacial
Orthop, 138, 396.e1-396.e9. CANGIALOSI, T. J. 1984. Skeletal morphologic features of anterior
open bite. Am J Orthod, 85, 28-36.
BALLARD, C. F. 1961. Oro-facial behaviour. Public Health, 76,
10-8. CANUTO, L. F., JANSON, G., DE LIMA, N. S., DE ALMEIDA, R.
R. & CANCADO, R. H. 2016. Anterior open-bite treatment with
BEHLFELT, K., LINDER-ARONSON, S. & NEANDER, P. 1990.
bonded vs conventional lingual spurs: A comparative study. Am J
Posture of the head, the hyoid bone, and the tongue in children
with and without enlarged tonsils. Eur J Orthod, 12, 458-67.
CAPON, P. 1944. Localized Vertical Growth Disturbances. Dent.
BELL, W. H. 1971. Correction of skeletal type of anterior open bite.
Record, 64, 127-132.
J Oral Surg, 29, 706-14.
CARANO, A., MACHATA, W. & SICILIANI, G. 2005a. Noncom-
BENINGTON, P. C., GARDENER, J. E. & HUNT, N. P. 1999.
pliant treatment of skeletal open bite. Am J Orthod Dentofacial
Masseter muscle volume measured using ultrasonography and its
Orthop, 128, 781-6.
relationship with facial morphology. Eur J Orthod, 21, 659-70.
CARANO, A. & MACHATA, W. C. 2002. A rapid molar intruder
BISASE, B., JOHNSON, P. & STACEY, M. 2010. Closure of the
for ‘non-compliance’ treatment. J Clin Orthod, 36, 137-42; quiz
anterior open bite using mandibular sagittal split osteotomy. Br J
145-6.
Oral Maxillofac Surg, 48, 352-5.
CARANO, A., SICILIANI, G. & BOWMAN, S. J. 2005b. Treat-
BJORK, A. 1966. Sutural growth of the upper face studied by the
ment of skeletal open bite with a device for rapid molar intrusion: a
implant method. Acta Odontol Scand, 24, 109-27.
preliminary report. Angle Orthod, 75, 736-46.
BJORK, A. 1969. Prediction of mandibular growth rotation. Am J
CARMICHAEL, G. J., BANKS, P. A. & CHADWICK, S. M. 1999. A
Orthod, 55, 585-99.
modification to enable controlled progressive advancement of the
BJÖRK, A. J. A. J. O. O. 1969. Prediction of mandibular growth Twin Block appliance. Br J Orthod, 26, 9-13.
rotation. 55, 585-599.
CHANG, Y. I. & MOON, S. C. 1999. Cephalometric evaluation of
190 Open Bite

the anterior open bite treatment. Am J Orthod Dentofacial Orthop, DIAMOND, O. 1980. Tonsils and adenoids: why the dilemma? Am
115, 29-38. J Orthod, 78, 495-503.
CLARK, W. 2010. Design and management of Twin Blocks: reflec- DUNG, D. J. & SMITH, R. J. 1988. Cephalometric and clinical di-
tions after 30 years of clinical use. J Orthod, 37, 209-16. agnoses of open bite tendency. American Journal of Orthodontics
CORRUCCINI, R. S. 1984. An epidemiologic transition in dental
occlusion in world populations. Am J Orthod, 86, 419-26. EGYEDI, P. 1964. Zur operativen zungenverkleinerung. Deutsch
Zahn Mund Kieferheilk Zentrabl, 41, 16-25.
COUSLEY, R. R. 2010. A clinical strategy for maxillary molar in-
trusion using orthodontic mini-implants and a customized palatal ELLIS, E., 3RD & MCNAMARA, J. A., JR. 1984. Components of
arch. J Orthod, 37, 202-8. adult Class III open-bite malocclusion. Am J Orthod, 86, 277-90.
COUSLEY, R. R. 2014. Molar intrusion in the management of ENACAR, A., UGUR, T. & TOROGLU, S. 1996. A method for cor-
anterior openbite and ‘high angle’ Class II malocclusions. J Orthod, rection of open bite. J Clin Orthod, 30, 43-8.
41 Suppl 1, S39-46.
ENLOW, D. H. & HUNTER, W. S. 1968. The growth of the face in
COZZA, P., BACCETTI, T., FRANCHI, L., MUCEDERO, M. & relation to the cranial base. Rep Congr Eur Orthod Soc, 44, 321-35.
POLIMENI, A. 2005. Sucking habits and facial hyperdivergency
ENUNLU, N. 1974. Palatal and mandibular plane variations in
as risk factors for anterior open bite in the mixed dentition. Am J
open bite cases with varying aetiology. Trans Eur Orthod Soc,
165-71.
COZZA, P., MUCEDERO, M., BACCETTI, T. & FRANCHI, L.
EPKER, B. N. & FISH, L. 1977. Surgical-orthodontic correction of
2007. Treatment and posttreatment effects of quad-helix/crib
open-bite deformity. Am J Orthod, 71, 278-99.
therapy of dentoskeletal open bite. Angle Orthod, 77, 640-5.
ERBAY, E., UGUR, T. & ULGEN, M. 1995a. The effects of Frankel’s
DA SILVA FILHO, O. G., DE FREITAS, S. F. & CAVASSAN ADE,
function regulator (FR-4) therapy on the treatment of Angle Class I
O. 1990. [Prevalence of normal occlusion and malocclusion in
skeletal anterior open bite malocclusion. Am J Orthod Dentofacial
Bauru (Sao Paulo) students. 2. Influence of socioeconomic level].
Orthop, 108, 9-21.
Rev Odontol Univ Sao Paulo, 4, 189-96.
ERBAY, E., UĞUR, T. & ULGEN, M. 1995b. The effects of Frankel’s
DAS, U. M. & BEENA, J. P. 2009. Effectiveness of circumoral
function regulator (FR-4) therapy on the treatment of Angle Class I
muscle exercises in the developing dentofacial morphology in
skeletal anterior open bite malocclusion. Am J Orthod Dentofacial
adenotonsillectomized children: an ultrasonographic evaluation. J
Orthop, 108, 9-21.
Indian Soc Pedod Prev Dent, 27, 94-103.
ERVERDI, N., KELES, A. & NANDA, R. 2004. The use of skeletal
DE CUEBAS, J. O. 1997. Nonsurgical treatment of a skeletal verti-
anchorage in open bite treatment: a cephalometric evaluation.
cal discrepancy with a significant open bite. Am J Orthod Dentofa-
cial Orthop, 112, 124-31.
ERVERDI, N., USUMEZ, S., SOLAK, A. & KOLDAS, T. 2007. Non-
DE FREITAS, M. R., BELTRÃO, R. T., JANSON, G., HENRIQUES,
compliance open-bite treatment with zygomatic anchorage. Angle
J. F. & CANÇADO, R. H. 2004. Long-term stability of anterior
Orthod, 77, 986-90.
open bite extraction treatment in the permanent dentition. Am J
Orthod Dentofacial Orthop, 125, 78-87. FERES, M. F., ABREU, L. G., INSABRALDE, N. M., DE AL-
MEIDA, M. R. & FLORES-MIR, C. 2017. Effectiveness of open
DEBERARDINIS, M., STRETESKY, T., SINHA, P. & NANDA, R.
bite correction when managing deleterious oral habits in growing
S. 2000. Evaluation of the vertical holding appliance in treatment of
children and adolescents: a systematic review and meta-analysis.
high-angle patients. Am J Orthod Dentofacial Orthop, 117, 700-5.
DEGAN, V. V. & PUPPIN-RONTANI, R. M. 2005. [Removal of
FERGUSON, J. W. 1995. The assessment and treatment of anterior
sucking habits and myofunctional therapy: establishing swallowing
open bite. Dent Update, 22, 163-8.
and tongue rest position]. Pro Fono, 17, 375-82.
FINLAY, J. A. & RICHARDSON, A. 1995. Outcome prediction in
DEGUCHI, T., KUROSAKA, H., OIKAWA, H., KURODA, S.,
open bite cases. Eur J Orthod, 17, 519-23.
TAKAHASHI, I., YAMASHIRO, T. & TAKANO-YAMAMOTO,
T. 2011. Comparison of orthodontic treatment outcomes in adults FIROUZ, M., ZERNIK, J. & NANDA, R. 1992. Dental and orthope-
with skeletal open bite between conventional edgewise treatment dic effects of high-pull headgear in treatment of Class II, division 1
and implant-anchored orthodontics. Am J Orthod Dentofacial malocclusion. Am J Orthod Dentofacial Orthop, 102, 197-205.
Orthop, 139, S60-8.
FRANKEL, R. & FRANKEL, C. 1983. A functional approach to
DELLINGER, E. L. 1986. A clinical assessment of the Active Verti- treatment of skeletal open bite. Am J Orthod, 84, 54-68.
cal Corrector--a nonsurgical alternative for skeletal open bite treat-
FRÄNKEL, R. & FRÄNKEL, C. 1983. A functional approach to
ment. Am J Orthod, 89, 428-36.
treatment of skeletal open bite. Am J Orthod, 84, 54-68.
DENISON, T. F., KOKICH, V. G. & SHAPIRO, P. A. 1989. Stability
GALLETTO, L., URBANIAK, J. & SUBTELNY, J. D. 1990. Adult
of maxillary surgery in openbite versus nonopenbite malocclusions.
anterior open bite. Am J Orthod Dentofacial Orthop, 97, 522-6.
Open Bite 191

GERSHATER, M. M. 1972. The proper perspective of open bite. Orthod, 60, 17-24; discussion 25-6.
HUNT, N. P. & CUNNINGHAM, S. J. 1997. The influence of or-
GESERICK, M., OLSBURGH, S. R. & PETERMANN, D. 2006. thognathic surgery on occlusal force in patients with vertical facial
The bite-jumping screw for modified twin-block treatment. J Clin deformities. Int J Oral Maxillofac Surg, 26, 87-91.
Orthod, 40, 432-5; quiz 420.
HWANG, D. H., PARK, K. H., KWON, Y. D. & KIM, S. J. 2011.
GILL, D. S., EL MAAYTAH, M. & NAINI, F. B. 2008. Risk fac- Treatment of Class II open bite complicated by an ankylosed maxil-
tors for post-orthognathic condylar resorption: a review. World J lary central incisor. Angle Orthod, 81, 726-35.
Orthod, 9, 21-5.
IANNETTI, G., FADDA, M. T., MARIANETTI, T. M., TERENZI,
GOIS, E. G., RIBEIRO-JUNIOR, H. C., VALE, M. P., PAIVA, S. V. & CASSONI, A. 2007. Long-term skeletal stability after surgical
M., SERRA-NEGRA, J. M., RAMOS-JORGE, M. L. & PORDEUS,
correction in Class III open-bite patients: a retrospective study on
I. A. 2008. Influence of nonnutritive sucking habits, breathing pat-
40 patients treated with mono- or bimaxillary surgery. J Craniofac
tern and adenoid size on the development of malocclusion. Angle
Surg, 18, 350-4.
Orthod, 78, 647-54.
INGERVALL, B. & HELKIMO, E. 1978. Masticatory muscle force
GOTTLIEB, D. J., VEZINA, R. M., CHASE, C., LESKO, S. M.,
and facial morphology in man. Arch Oral Biol, 23, 203-6.
HEEREN, T. C., WEESE-MAYER, D. E., AUERBACH, S. H. &
CORWIN, M. J. 2003. Symptoms of sleep-disordered breathing INGERVALL, B. & SCHMOKER, R. 1990. Effect of surgical reduc-
in 5-year-old children are associated with sleepiness and problem tion of the tongue on oral stereognosis, oral motor ability, and the
behaviors. Pediatrics, 112, 870-7. rest position of the tongue and mandible. Am J Orthod Dentofacial
Orthop, 97, 58-65.
GREENLEE, G. M., HUANG, G. J., CHEN, S. S., CHEN, J., KO-
EPSELL, T. & HUJOEL, P. 2011. Stability of treatment for anterior INGERVALL, B. & THILANDER, B. 1974. Relation between facial
open-bite malocclusion: a meta-analysis. Am J Orthod Dentofacial morphology and activity of the masticatory muscles. J Oral Reha-
Orthop, 139, 154-69. bil, 1, 131-47.
HARVOLD, E. P., CHIERICI, G. & VARGERVIK, K. 1972. Experi- INSABRALDE, N. M., DE ALMEIDA, R. R., HENRIQUES, J. F.,
ments on the development of dental malocclusions. Am J Orthod, FERNANDES, T. M., FLORES-MIR, C. & DE ALMEIDA, M. R.
61, 38-44. 2016. Dentoskeletal effects produced by removable palatal crib,
bonded spurs, and chincup therapy in growing children with ante-
HARYETT, R. D., HANSEN, F. C. & DAVIDSON, P. O. 1970.
rior open bite. Angle Orthod, 86, 969-975.
Chronic thumb-sucking. A second report on treatment and its
psychological effects. Am J Orthod, 57, 164-78. IRELAND, A. J. 1991. Familial posterior open bite: a primary
failure of eruption. Br J Orthod, 18, 233-7.
HARYETT, R. D., HANSEN, F. C., DAVIDSON, P. O. & SANDI-
LANDS, M. L. 1967. Chronic thumb-sucking: the psychologic ef- IŞCAN, H. N., AKKAYA, S. & KORALP, E. 1992. The effects of the
fects and the relative effectiveness of various methods of treatment. spring-loaded posterior bite-block on the maxillo-facial morphol-
Am J Orthod, 53, 569-85. ogy. Eur J Orthod, 14, 54-60.
HASKELL, B. S. & MINK, J. R. 1991. An aid to stop thumb sucking: IŞCAN, H. N., DINÇER, M., GÜLTAN, A., MERAL, O. &
the “Bluegrass” appliance. Pediatr Dent, 13, 83-5. TANER-SARISOY, L. 2002. Effects of vertical chincap therapy on
the mandibular morphology in open-bite patients. Am J Orthod
HAYDAR, B. & ENACAR, A. 1992. Functional regulator therapy in
treatment of skeletal open-bite. J Nihon Univ Sch Dent, 34, 278-87.
ISCAN, H. N. & SARISOY, L. 1997. Comparison of the effects of
HIRANAKA, D. K. & KELLY, J. P. 1987. Stability of simultaneous
passive posterior bite-blocks with different construction bites on
orthognathic surgery on the maxilla and mandible: a computer-
the craniofacial and dentoalveolar structures. Am J Orthod Dento-
assisted cephalometric study. Int J Adult Orthodon Orthognath
Surg, 2, 193-213.
JACOBSON, A. 1986. Orthodontics: State of the art, essence of
HOPPENREIJS, T. J., FREIHOFER, H. P., STOELINGA, P. J.,
the science: Lee W. Graber (editor) St. Louis, 1986, The CV Mosby
TUINZING, D. B., VAN’T HOF, M. A., VAN DER LINDEN, F. P. &
Company. 421 pages, 574 illustrations. American Journal of Ortho-
NOTTET, S. J. 1997. Skeletal and dento-alveolar stability of Le Fort
dontics and Dentofacial Orthopedics, 90, 173-174.
I intrusion osteotomies and bimaxillary osteotomies in anterior
open bite deformities. A retrospective three-centre study. Int J Oral JANSON, G., CREPALDI, M. V., DE FREITAS, K. M., DE FREI-
Maxillofac Surg, 26, 161-75. TAS, M. R. & JANSON, W. 2008. Evaluation of anterior open-bite
treatment with occlusal adjustment. Am J Orthod Dentofacial
HOUSTON, W., STEPHENS, C. & TULLEY, W. 1992. A Textbook
Orthop, 134, 10-1.
of Orthodontics. 2nd edn. Wright. Oxford, 18, 350-2.
JANSON, G., VALARELLI, F. P., BELTRAO, R. T., DE FREITAS,
HUANG, G. J. Long-term stability of anterior open-bitetherapy: A
M. R. & HENRIQUES, J. F. 2006. Stability of anterior open-bite ex-
review. Seminars in Orthodontics, 2002. Elsevier, 162-172.
traction and nonextraction treatment in the permanent dentition.
HUANG, G. J., JUSTUS, R., KENNEDY, D. B. & KOKICH, V. G. Am J Orthod Dentofacial Orthop, 129, 768-74.
1990. Stability of anterior openbite treated with crib therapy. Angle
192 Open Bite

JARABAK, J. R. & FIZZELL, J. A. 1972. Technique and treatment J Am Dent Assoc, 138, 56-64.
with light-wire edgewise applications. 1, Mosby.
KÜÇÜKKELEŞ, N., ACAR, A., DEMIRKAYA, A. A., EVRENOL,
JENNER, J. D. & FITZPATRICK, B. N. 1985. Skeletal anchorage B. & ENACAR, A. 1999. Cephalometric evaluation of open bite
utilising bone plates. Aust Orthod J, 9, 231-3. treatment with NiTi arch wires and anterior elastics. Am J Orthod
JULIANO, M. L., MACHADO, M. A. C., PRADO, L. B. F. D., CAR-
VALHO, L. B. C. D., CARVALHO, F. R. D., LENTINI-OLIVEIRA, KUHN, R. J. 1968. Control of anterior vertical dimension and
D. A., MACEDO, C. & PRADO, G. F. D. 2005. Craniofacial proper selection of extraoral anchorage. Angle Orthod, 38, 340-9.
morphology of oral breathing children relates to obstructive sleep
KURODA, S., SAKAI, Y., TAMAMURA, N., DEGUCHI, T. &
apnea cephalometric pattern. Sleep.
TAKANO-YAMAMOTO, T. 2007. Treatment of severe anterior
JUSTUS, R. 2001. Correction of Anterior Open Bite with Spurs: open bite with skeletal anchorage in adults: comparison with
Long-Term Stability. World Journal of Orthodontics, 2. orthognathic surgery outcomes. Am J Orthod Dentofacial Orthop,
132, 599-605.
KALRA, V., BURSTONE, C. J. & NANDA, R. 1989. Effects of a
fixed magnetic appliance on the dentofacial complex. Am J Orthod KUROL, J. 1981. Infraocclusion of primary molars: an epidemio-
Dentofacial Orthop, 95, 467-78. logic and familial study. Community Dent Oral Epidemiol, 9,
94-102.
KASSIR, C. & SAADE, A. 2017. Nonsurgical Treatment of a Severe
Skeletal Anterior Open Bite. J Clin Orthod, 51, 103-112. KUSTER, R. & INGERVALL, B. 1992. The effect of treatment of
skeletal open bite with two types of bite-blocks. Eur J Orthod, 14,
KELLY, J. E., SANCHEZ, M. & VAN KIRK, L. E. 1973. An Assess-
489-99.
ment of the Occlusion of the Teeth of Children 6-11Years, United
States. Vital Health Stat 11, 1-60. LARSSON, E. 1971. Dummy- and finger-sucking habits with spe-
cial attention to their significance for facial growth and occlusion.
KIKUCHI, M., HIGURASHI, N., MIYAZAKI, S., ITASAKA, Y.,
1. Incidence study. Sven Tandlak Tidskr, 64, 667-72.
CHIBA, S. & NEZU, H. 2002. Facial pattern categories of sleep
breathing-disordered children using Ricketts analysis. Psychiatry LARSSON, E. 1986. The effect of dummy-sucking on the occlusion:
Clin Neurosci, 56, 329-30. a review. Eur J Orthod, 8, 127-30.
KILIARIDIS, S., EGERMARK, I. & THILANDER, B. 1990. Ante- LARSSON, E. 1987. The effect of finger-sucking on the occlusion: a
rior open bite treatment with magnets. Eur J Orthod, 12, 447-57. review. Eur J Orthod, 9, 279-82.
KILIARIDIS, S., JOHANSSON, A., HARALDSON, T., OMAR, LAWRY, D. M., HEGGIE, A. A., CRAWFORD, E. C. & RULJAN-
R. & CARLSSON, G. E. 1995. Craniofacial morphology, occlusal CICH, M. K. 1990. A review of the management of anterior open
traits, and bite force in persons with advanced occlusal tooth wear. bite malocclusion. Aust Orthod J, 11, 147-60.
LEE, J. S., KIM, D. H., PARK, Y. C., KYUNG, S. H. & KIM, T. K.
KILLEY, H. C. 1983. Killey’s fractures of the mandible, Wright. 2004. The efficient use of midpalatal miniscrew implants. Angle
Orthod, 74, 711-4.
KILLEY, H. C. & BANKS, P. 1987. Killey’s fractures of the middle
third of the facial skeleton, Butterworth-Heinemann. LEITE, J. S., MATIUSSI, L. B., SALEM, A. C., PROVENZANO, M.
G. & RAMOS, A. L. 2016. Effects of palatal crib and bonded spurs
KIM, Y. H. 1974. Overbite depth indicator with particular refer-
in early treatment of anterior open bite: A prospective randomized
ence to anterior open-bite. American Journal of Orthodontics and
clinical study. Angle Orthod, 86, 734-9.
LEMBRECHTS, D., VERSCHUEREN, D., HEULENS, H.,
KIM, Y. H. 1987. Anterior openbite and its treatment with multi-
VALKENBURG, H. A. & FEENSTRA, L. 1999. Effect of a logopedic
loop edgewise archwire. Angle Orthod, 57, 290-321.
instruction program after adenoidectomy on open mouth posture:
KIM, Y. H., HAN, U. K., LIM, D. D. & SERRAON, M. L. 2000. a single-blind study. Folia Phoniatr Logop, 51, 117-23.
Stability of anterior openbite correction with multiloop edgewise
LENTINI-OLIVEIRA, D., CARVALHO, F. R., QINGSONG, Y.,
archwire therapy: A cephalometric follow-up study. Am J Orthod
JUNJIE, L., SACONATO, H., MACHADO, M. A., PRADO, L. B.
& PRADO, G. F. 2007. Orthodontic and orthopaedic treatment
KOLETSI, D., MAKOU, M. & PANDIS, N. 2018. Effect of orth- for anterior open bite in children. Cochrane Database Syst Rev,
odontic management and orofacial muscle training protocols on Cd005515.
the correction of myofunctional and myoskeletal problems in de-
LI, D. K., WILLINGER, M., PETITTI, D. B., ODOULI, R., LIU,
veloping dentition. A systematic review and meta-analysis. Orthod
L. & HOFFMAN, H. J. 2006. Use of a dummy (pacifier) during
Craniofac Res, 21, 202-215.
sleep and risk of sudden infant death syndrome (SIDS): population
KORBMACHER, H. M., SCHWAN, M., BERNDSEN, S., BULL, based case-control study. Bmj, 332, 18-22.
J. & KAHL-NIEKE, B. 2004. Evaluation of a new concept of myo-
LINDER-ARONSON, S. 1970. Adenoids. Their effect on mode of
functional therapy in children. Int J Orofacial Myology, 30, 39-52.
breathing and nasal airflow and their relationship to characteristics
KRAVITZ, N. D., KUSNOTO, B., TSAY, T. P. & HOHLT, W. F. of the facial skeleton and the denition. A biometric, rhino-mano-
2007. The use of temporary anchorage devices for molar intrusion. metric and cephalometro-radiographic study on children with and
Open Bite 193

without adenoids. Acta Otolaryngol Suppl, 265, 1-132. NAHOUM, H. I. 1971. Vertical proportions and the palatal plane
in anterior open-bite. Am J Orthod, 59, 273-82.
LINDER-ARONSON, S. 1973. Effects of adenoidectomy on mode
of breathing, size of adenoids and nasal airflow. ORL J Otorhinolar- NAHOUM, H. I. 1975. Anterior open-bite: a cephalometric analy-
yngol Relat Spec, 35, 283-302. sis and suggested treatment procedures. Am J Orthod, 67, 523-21.
LINDER-ARONSON, S. 1974. Effects of adenoidectomy on denti- NAHOUM, H. I. 1977. Vertical proportions: a guide for prognosis
tion and nasopharynx. American Journal of Orthodontics, 65, and treatment in anterior open-bite. Am J Orthod, 72, 128-46.
1-15.
NAHOUM, H. I., HOROWITZ, S. L. & BENEDICTO, E. A. 1972.
LINDER-ARONSON, S. 1983. “The relation between nasorespi- Varieties of anterior open-bite. Am J Orthod, 61, 486-92.
ratory function and dentofacial morphology”. Am J Orthod, 83,
NAINI, F. B. 2011. Facial aesthetics: concepts and clinical diagno-
443-4.
sis, John Wiley & Sons.
LING, H. T. B., SUM, F., ZHANG, L., YEUNG, C. P. W., LI, K. Y.,
NAINI, F. B., COBOURNE, M. T., MCDONALD, F. & WERT-
WONG, H. M. & YANG, Y. 2018. The association between nutri-
HEIM, D. 2015. The aesthetic impact of upper lip inclination in
tive, non-nutritive sucking habits and primary dental occlusion.
orthodontics and orthognathic surgery. Eur J Orthod, 37, 81-6.
BMC Oral Health, 18, 145.
NAINI, F. B. & GILL, D. S. 2017. Principles of orthognathic surgical
LOPEZ-GAVITO, G., WALLEN, T. R., LITTLE, R. M. &
correction of skeletal anterior open bite. APOS Trends in Ortho-
JOONDEPH, D. R. 1985. Anterior open-bite malocclusion: a longi-
dontics, 7, 157-167.
tudinal 10-year postretention evaluation of orthodontically treated
patients. Am J Orthod, 87, 175-86. NAINI, F. B., STEWART, A. & GILL, D. S. 2016. Surgical correction
of anterior open bite: Differential posterior maxillary impaction.
LOUKOTA, R. A. & MCCANN, P. J. 2003. Condylar neck fracture:
Orthognathic Surgery: Principles, Planning and Practice, 498-520.
Peter WB. Barry LE. Rainer S. Maxillofacial trauma and Esthetic
facial reconstruction 1st ed. Philadephia, Churchill Living stone, NG, C. S., WONG, W. K. & HAGG, U. 2008. Orthodontic treat-
281-290. ment of anterior open bite. Int J Paediatr Dent, 18, 78-83.
MCNAMARA, J. A., JR. 1977. An experimental study of increased NGAN, P. & FIELDS, H. W. 1997. Open bite: a review of etiology
vertical dimension in the growing face. Am J Orthod, 71, 382-95. and management. Pediatr Dent, 19, 91-8.
MEDEIROS, R. B., DE ARAÚJO, L. F. C., MUCHA, J. N. & MOT- NGAN, P., WILSON, S., FLORMAN, M. & WEI, S. H. 1992. Treat-
TA, A. T. 2012. Stability of open-bite treatment in adult patients: A ment of Class II open bite in the mixed dentition with a removable
systematic review. Journal of the World Federation of Orthodon- functional appliance and headgear. Quintessence Int, 23, 323-33.
tists, 1, e97-e101.
NIELSEN, I. L. J. T. A. O. 1991. Vertical malocclusions: etiology,
MELSEN, B., AGERBAEK, N., ERIKSEN, J. & TERP, S. 1988. New development, diagnosis and some aspects of treatment. 61, 247-
attachment through periodontal treatment and orthodontic intru- 260.
sion. Am J Orthod Dentofacial Orthop, 94, 104-16.
NOAR, J. & PORTNOY, S. 1991. Dental status of children in a pri-
MELSEN, B., ATTINA, L., SANTUARI, M. & ATTINA, A. 1987. mary and secondary school in rural Zambia. Int Dent J, 41, 142-8.
NOAR, J. H., SHELL, N. & HUNT, N. P. 1996. The performance of
Relationships between swallowing pattern, mode of respiration,
bonded magnets used in the treatment of anterior open bite. Am J
and development of malocclusion. Angle Orthod, 57, 113-20.
Orthod Dentofacial Orthop, 109, 549-56; discussion 557.
MIYAWAKI, S., KOYAMA, I., INOUE, M., MISHIMA, K., SUGA-
O’BRIEN, L. M., TAUMAN, R. & GOZAL, D. 2004. Sleep pres-
HARA, T. & TAKANO-YAMAMOTO, T. 2003. Factors associated
sure correlates of cognitive and behavioral morbidity in snoring
with the stability of titanium screws placed in the posterior region
children. Sleep, 27, 279-82.
for orthodontic anchorage. Am J Orthod Dentofacial Orthop, 124,
373-8. O’BRIEN, M., O’BRIEN, M., O’BRIEN, M. & O’BRIEN, J. 1994.
Children’s dental health in the United Kingdom 1993.
MIZRAHI, E. 1978. A review of anterior open bite. Br J Orthod, 5,
21-7. PARK, H. S., KWON, O. W. & SUNG, J. H. 2006. Nonextraction
treatment of an open bite with microscrew implant anchorage. Am
MOLLER, E. 1966. The chewing apparatus. An electromyographic
study of the action of the muscles of mastication and its correlation
to facial morphology. Acta Physiol Scand Suppl, 280, 1-229. PARK, H. S., KWON, T. G. & KWON, O. W. 2004. Treatment of
open bite with microscrew implant anchorage. Am J Orthod Den-
MOSS, M. L. & SALENTIJN, L. 1971. Differences between the
tofacial Orthop, 126, 627-36.
functional matrices in anterior open-bite and in deep overbite. Am
J Orthod, 60, 264-80. PARKER, J. H. 1971. The interception of the open bite in the early
growth period. Angle Orthod, 41, 24-44.
MUCEDERO, M., FRANCHI, L., GIUNTINI, V., VANGELISTI,
A., MCNAMARA, J. A., JR. & COZZA, P. 2013. Stability of quad- PARKIN, N. A., MCKEOWN, H. F. & SANDLER, P. J. 2001. Com-
helix/crib therapy in dentoskeletal open bite: a long-term con- parison of 2 modifications of the twin-block appliance in matched
trolled study. Am J Orthod Dentofacial Orthop, 143, 695-703. Class II samples. Am J Orthod Dentofacial Orthop, 119, 572-7.
194 Open Bite

PARKS, L. R., BUSCHANG, P. H., ALEXANDER, R. A., RODRIGUES DE ALMEIDA, R. & URSI, W. J. 1990. Anterior open
DECHOW, P. & ROSSOUW, P. E. 2007. Masticatory exercise as an bite. Etiology and treatment. Oral Health, 80, 27-31.
adjunctive treatment for hyperdivergent patients. Angle Orthod,
ROWLERSON, A., RAOUL, G., DANIEL, Y., CLOSE, J., MAU-
77, 457-62.
RAGE, C. A., FERRI, J. & SCIOTE, J. J. 2005. Fiber-type differences
PEARSON, L. Treatment of vertical backward rotating type growth in masseter muscle associated with different facial morphologies.
pattern patients in today’s environment. Meeting of Southern As- Am J Orthod Dentofacial Orthop, 127, 37-46.
soc of Orthodontists, 1996.
SAKAI, Y., KURODA, S., MURSHID, S. A. & TAKANO-YAMA-
PEARSON, L. E. 1973. Vertical control through use of mandibular MOTO, T. 2008. Skeletal Class lll severe openbite treatment using
posterior intrusive forces. Angle Orthod, 43, 194-200. implant anchorage. Angle Orthod, 78, 157-66.
PEARSON, L. E. 1978. Vertical control in treatment of patients SANDLER, P. J., MADAHAR, A. K. & MURRAY, A. 2011. Anterior
having backward-rotational growth tendencies. Angle Orthod, 48, open bite: aetiology and management. Dent Update, 38, 522-4,
132-40. 527-8, 531-2.
PEARSON, L. E. 1986. Vertical control in fully-banded orthodontic SANKEY, W. L., BUSCHANG, P. H., ENGLISH, J. & OWEN, A.
treatment. Angle Orthod, 56, 205-24. H., 3RD 2000. Early treatment of vertical skeletal dysplasia: the
hyperdivergent phenotype. Am J Orthod Dentofacial Orthop, 118,
PEDRIN, F., ALMEIDA, M. R., ALMEIDA, R. R., ALMEIDA-PE-
317-27.
DRIN, R. R. & TORRES, F. 2006. A prospective study of the treat-
ment effects of a removable appliance with palatal crib combined SASSOUNI, V. 1969. A classification of skeletal facial types. Am J
with high-pull chincup therapy in anterior open-bite patients. Am J Orthod, 55, 109-23.
SASSOUNI, V. & NANDA, S. 1964. Analysis of dentofacial vertical
PEREIRA, S. R., WECKX, L. L., ORTOLANI, C. L. & BAKOR, S. F. proportions. American Journal of Orthodontics, 50, 801-823.
2012. Study of craniofacial alterations and of the importance of the
SCHEFFLER, N. R., PROFFIT, W. R. & PHILLIPS, C. 2014. Out-
rapid maxillary expansion after tonsillectomy. Braz J Otorhinolar-
comes and stability in patients with anterior open bite and long
yngol, 78, 111-7.
anterior face height treated with temporary anchorage devices and
POULTON, D. R. 1967. The influence of extraoral traction. Am J a maxillary intrusion splint. Am J Orthod Dentofacial Orthop, 146,
Orthod, 53, 8-18. 594-602.
PROFFIT, W. R. 1978. Equilibrium theory revisited: factors influ- SHANKER, S., FIELDS, H. W., BECK, F., VIG, P. & VIG, K. A lon-
encing position of the teeth. Angle Orthod, 48, 175-86. gitudinal assessment of upper respiratory function and dentofacial
morphology in 8-to 12-year-old children. Seminars in Orthodon-
PROFFIT, W. R., FIELDS, H. & SARVER, D. 2007. Contemporary
tics, 2004. Elsevier, 45-53.
orthodontics 4th ed. Philadelphia: Mosby.
SHERWOOD, K. 2007. Correction of skeletal open bite with
PROFFIT, W. R. & FIELDS, H. W. 1983. Occlusal forces in normal-
implant anchored molar/bicuspid intrusion. Oral Maxillofac Surg
and long-face children. J Dent Res, 62, 571-4.
Clin North Am, 19, 339-50, vi.
PROFFIT, W. R., FIELDS, H. W. & NIXON, W. L. 1983. Occlusal
SHIRA, R. B. 1961. Surgical Correction of Open Bite Deformaties
forces in normal- and long-face adults. J Dent Res, 62, 566-70.
by Oblique Sliding Osteotomy, US Government Printing Office.
PROFFIT, W. R. & MASON, R. M. 1975. Myofunctional therapy
SIRIWAT, P. P. & JARABAK, J. R. 1985. Malocclusion and facial
for tongue-thrusting: background and recommendations. J Am
morphology is there a relationship? An epidemiologic study. Angle
Dent Assoc, 90, 403-11.
Orthod, 55, 127-38.
RAKOSI, T. & JONAS, I. 1993. Orthodontic diagnosis, G. Thieme
SLAVIERO, T., FERNANDES, T. M., OLTRAMARI-NAVARRO, P.
Verlag;.
V., DE CASTRO, A. C., CONTI, F., POLETI, M. L. & DE ALMEI-
REYNEKE, J. P. & FERRETTI, C. 2007. Anterior open bite correc- DA, M. R. 2017. Dimensional changes of dental arches produced
tion by Le Fort I or bilateral sagittal split osteotomy. Oral Maxillo- by fixed and removable palatal cribs: A prospective, randomized,
fac Surg Clin North Am, 19, 321-38, v. controlled study. Angle Orthod, 87, 215-222.
RICHARDSON, A. 1967. A cephalometric investigation of skeletal SMEDJE, H., BROMAN, J. E. & HETTA, J. 2001. Associations be-
factors in anterior open bite and deep overbite. Rep Congr Eur tween disturbed sleep and behavioural difficulties in 635 children
Orthod Soc, 159-71. aged six to eight years: a study based on parents’ perceptions. Eur
Child Adolesc Psychiatry, 10, 1-9.
RICHARDSON, A. 1981. A classification of open bites. Eur J
Orthod, 3, 289-96. SMITHPETER, J. & COVELL, D., JR. 2010. Relapse of anterior
open bites treated with orthodontic appliances with and without
RICKETTS, R. M. 1968. Respiratory obstruction syndrome. Am J
orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop,
Orthod, 54, 495-507.
137, 605-14.
RINGQVIST, M. 1973. Isometric bite force and its relation to di-
SOLANO-HERNÁNDEZ, B., ANTONARAKIS, G. S., SCOLOZZI,
mensions of the facial skeleton. Acta Odontol Scand, 31, 35-42.
P. & KILIARIDIS, S. 2013. Combined orthodontic and orthogna-
Open Bite 195

thic surgical treatment for the correction of skeletal anterior open- A prospective randomized study. Eur J Orthod, 28, 610-7.
bite malocclusion: a systematic review on vertical stability. J Oral
TORRES, F. C., ALMEIDA, R. R., ALMEIDA-PEDRIN, R. R.,
Maxillofac Surg, 71, 98-109.
PEDRIN, F. & PARANHOS, L. R. 2012. Dentoalveolar comparative
SOLOW, B. 1980. The dentoalveolar compensatory mechanism: study between removable and fixed cribs, associated to chincup, in
background and clinical implications. Br J Orthod, 7, 145-61. anterior open bite treatment. J Appl Oral Sci, 20, 531-7.
SOLOW, B. & TALLGREN, A. 1976. Head posture and craniofacial UMEMORI, M., SUGAWARA, J., MITANI, H., NAGASAKA, H.
morphology. Am J Phys Anthropol, 44, 417-35. & KAWAMURA, H. 1999. Skeletal anchorage system for open-bite
correction. Am J Orthod Dentofacial Orthop, 115, 166-74.
SOUKI, B. Q., PIMENTA, G. B., FRANCO, L. P., BECKER, H. M.
& PINTO, J. A. 2010. Changes in vertical dentofacial morphology URIBE, F., JANAKIRAMAN, N., FATTAL, A. N., PADALA, S. &
after adeno-/tonsillectomy during deciduous and mixed dentitions NANDA, R. 2013. A biomechanical approach to second-molar
mouth breathing children--1 year follow-up study. Int J Pediatr intrusion. J Clin Orthod, 47, 608-13.
Otorhinolaryngol, 74, 626-32.
VANARSDALL, R. L. 1995. Orthodontics and periodontal therapy.
STRAUB, W. J. 1960. Malfunction of the tongue: Part I. The ab- Periodontol 2000, 9, 132-49.
normal swallowing habit: Its cause, effects, and results in relation
VÁZQUEZ-NAVA, F., QUEZADA-CASTILLO, J., OVIEDO-TRE-
to orthodontic treatment and speech therapy. American Journal of
VINO, S., SALDIVAR-GONZÁLEZ, A., SÁNCHEZ-NUNCIO, H.,
Orthodontics, 46, 404-424.
BELTRÁN-GUZMÁN, F., VAZQUEZ-RODRIGUEZ, E. & RODRÍ-
SUBTELNY, J. D. 1965. EXAMINATION OF CURRENT PHI- GUEZ, C. V. 2006. Association between allergic rhinitis, bottle
LOSOPHIES ASSOCIATED WITH SWALLOWING BEHAVIOR. feeding, non-nutritive sucking habits, and malocclusion in the
Am J Orthod, 51, 161-82. primary dentition. Archives of disease in childhood, 91, 836-840.
SUBTELNY, J. D. & SAKUDA, M. 1964. Open-bite: diagnosis VIG, K. W. 1998. Nasal obstruction and facial growth: the strength
and treatment. American journal of orthodontics and dentofacial of evidence for clinical assumptions. Am J Orthod Dentofacial
orthopedics, 50, 337-358. Orthop, 113, 603-11.
SUGAWARA, J., BAIK, U. B., UMEMORI, M., TAKAHASHI, I., WATSON, W. G. 1972. A computerized appraisal of the high-pull
NAGASAKA, H., KAWAMURA, H. & MITANI, H. 2002. Treat- face-bow. Am J Orthod, 62, 561-79.
ment and posttreatment dentoalveolar changes following intrusion
WEINBACH, J. R. & SMITH, R. J. 1992. Cephalometric changes
of mandibular molars with application of a skeletal anchorage sys-
during treatment with the open bite bionator. Am J Orthod Dento-
tem (SAS) for open bite correction. Int J Adult Orthodon Orthog-
nath Surg, 17, 243-53.
WILSON, M. D. 1996. Vertical control of maxillary molar position
SWINNEN, K., POLITIS, C., WILLEMS, G., DE BRUYNE, I.,
with a palatal appliance. University of Oklahoma.
FIEUWS, S., HEIDBUCHEL, K., VAN ERUM, R., VERDONCK,
A. & CARELS, C. 2001. Skeletal and dento-alveolar stability after WISE, J. B., MAGNESS, W. B. & POWERS, J. M. 1994. Maxillary
surgical-orthodontic treatment of anterior open bite: a retrospec- molar vertical control with the use of transpalatal arches. Am J
tive study. Eur J Orthod, 23, 547-57. Orthod Dentofacial Orthop, 106, 403-8.
TASLAN, S., BIREN, S. & CEYLANOGLU, C. 2010. Tongue pres- WOODSIDE, D. G., LINDER-ARONSON, S., LUNDSTROM, A.
sure changes before, during and after crib appliance therapy. Angle & MCWILLIAM, J. 1991. Mandibular and maxillary growth after
Orthod, 80, 533-9. changed mode of breathing. Am J Orthod Dentofacial Orthop, 100,
1-18.
TAUSCHE, E., LUCK, O. & HARZER, W. 2004. Prevalence of mal-
occlusions in the early mixed dentition and orthodontic treatment WORMS, F. W., MESKIN, L. H. & ISAACSON, R. J. 1971. Open-
need. Eur J Orthod, 26, 237-44. bite. Am J Orthod, 59, 589-95.
TEUSCHER, U. 1978. A growth-related concept for skeletal class II XUN, C., ZENG, X. & WANG, X. 2007. Microscrew anchorage in
treatment. Am J Orthod, 74, 258-75. skeletal anterior open-bite treatment. The Angle Orthodontist, 77,
47-56.
TEUSCHER, U. 1986. An appraisal of growth and reaction to
extraoral anchorage. Simulation of orthodontic-orthopedic results. ZUROFF, J. P., CHEN, S. H., SHAPIRO, P. A., LITTLE, R. M.,
Am J Orthod, 89, 113-21. JOONDEPH, D. R. & HUANG, G. J. 2010. Orthodontic treatment
of anterior open-bite malocclusion: stability 10 years postretention.
THOMA, K. H. 1943. Y-shaped osteotomy for correction of open
Am J Orthod Dentofacial Orthop, 137, 302.e1-8; discussion 302-3.
bite in adults. American Journal of Orthodontics and Oral Surgery,
29, B465-B479.
TODD, J. E. & WHITWORTH, A. 1974. Adult dental health in
Scotland 1972. Br Dent J, 137, 139-42.
TORRES, F., ALMEIDA, R. R., DE ALMEIDA, M. R., ALMEIDA-
PEDRIN, R. R., PEDRIN, F. & HENRIQUES, J. F. 2006. Anterior
open bite treated with a palatal crib and high-pull chin cup therapy.
196 Open Bite

Open Bite 197
Deep bite
19
In this Chapter
1. Basic terminologies
2. Prevalence
3. Aetiology deep overbite
4. Principles of deep incisor overbite reduction
5. Method of treating DOB
6. Management of overbite
O verbite (OB) describes the vertical overlap of the upper
gulum.
Principles of deep incisor overbite reduction
and lower incisors measured perpendicular to the occlusal
plane with the posterior teeth in the occlusion (BSI 1983). These include:
OB is measured perpendicular to the occlusal plane in mm or
• True incisor intrusion is mainly indicated in an
expressed as a ratio. The normal range for the maxillary inci-
adult patient with excessive maxillary incisors show-
sors to vertically overlap the mandibular incisors is 2–4 mm,
ing at rest and a patient with long lower facial height
or one-third to one-half of mandibular incisors crown height.
with over erupted incisors.
Basic terminologies
• Levelling of the arch through molar and premolar
These include: eruption and extrusion (Cobourne and DiBiase,
• Deep bite: When the maxillary incisors overlap, the 2015). Keeping in mind that the condyle will com-
mandibular incisor crowns vertically by greater than pensate for the extrusion in a growing patient and
one-half of the lower incisor crown height. maintain the anterioposterior relationship, but in
the adult, the condyle does not compensate for that
• Complete: There is contact between incisors or the (McDowell & Baker, 1991). however, the slight hing-
incisors and opposing mucosa. ing open of the mandible in adults, associated with
• Incomplete: if there is no contact between incisors molar extrusion, seems to be stable due to the ten-
or the incisors and opposing mucosa. dency to small continued vertical growth found in
adults (Behrents 1986).
• Traumatic overbite: When the increased overbite is
causing trauma to the upper or lower mucosa. Up- • Incisor proclination or relative incisor intrusion
per incisors mainly cause trauma to the lower labial (Ireland et al., 2016). Eberhart et al. (1990) stated
mucosa, especially in the case of class II div 2. In that 5 degrees of incisor proclination reduced the
contrast, the lower incisors can cause upper palatal overbite by 1 mm on average.
mucosa in the case of class I div and div II. • Distal tipping of posterior teeth
Prevalence • Surgery to change the anteroposterior and vertical
Worldwide, the prevalence is 11.13 % in mixed dentition and relationship.
14.98% in the permanent dentition (Alhammadi, 2018). Consideration factors for the method of treating DOB
Aetiology deep overbite These include:
These include: • Age and the remaining growth affect the degree of
• Skeletal and growth factors: A reduced lower face incisor show. It is preferable to accept slightly in-
height in conjunction with a Class II jaw relation- creased incisor show in the growing patient since
ship results in the absence of an occlusal stop to the soft tissue maturation would mask some of the un-
lower incisors, which subsequently over-erupt lead- derlying problems with ageing
ing to an increased overbite (Pancherz et al., 1997). • Patient compliance and concerns
Forward growth rotation, i.e. counter-clockwise
(average -7°), can cause skeletal deep bite leading • Vertical height relationship: For instance, it is rec-
to decreased anterior lower face height or increased ommended to avoid posterior teeth extrusion in
posterior face height (Nielsen, 1991). high angle cases.
• Soft Tissues such as high lower lip line (Nicole 1954, • Faial profile: It is recommended to avoid relative in-
Ridley 1960), hyperactive or “strap-like” lower lip trusion (proclination of incisors) in full or convex
(Lapatki et al., 2002), and hyperactive Mentalis mus- profile.
cle (Karlsen, 1994). These soft tissue factors result in • If the main aim of the treatment is to reduce the
deep bite by retroclination of the lower incisor. amount of incisor show, then absolute intrusion is
• Dental factors such as overeruption of the incisors, indicated. Generally, the incisors show they depend
long central and short lateral incisors, which results on the following factors: Lip length, crown height,
in the lateral incisors ‘escaping’ from the effects of lip activity, gingival height and level and the degree
the lower lip force, increased crown root angle of the of anterior maxillary height.
upper incisor, known as the Collum angle (McIntyre • Incisor inclination at the start of the treatment: If
and Millett, 2003), and thin incisors with small cin- the incisor is retroclined, deep bite management via
200 DEEP BITE

relative intrusion is preferable. • Bonding the second permanent molar leads to addi-
tional vertical posterior anchorage and second mo-
• In the thin gingival biotype (labial surface of inci-
lar extrusion.
sors), management of the deep bite via relative intru-
sion should be avoided. 6. Continuous rigid archwires: Levelling of the curve of
Spee can be accomplished with continuous archwires by plac-
• Intra-arch relationship such as the overjet and the
ing an exaggerated curve of Spee in the upper archwire and
arch length discrepancy. If the arch is crowded or the
a reverse curve of Spee in the lower archwire. Although it
overjet is reduced, reducing the overbite by proclina-
is recommended to use a rectangular archwire for this pur-
tion of incisors is preferable.
pose, Al-Qabandi et al., in 1999, carried out a prospective
Management of overbite randomised clinical study to compare the effects of rectan-
gular and round archwires in levelling the curve Spee and
These include:
they found no significant difference in incisor proclination
1. Upper removable appliance (URA): URA with anterior between these two groups.
bite plane in a growing patient can be used to correct deep
7. Counterforce or rocking chair NiTi archwires (Modi-
bite (Millett et al., 2006). Providing that the rate of molar
fied Tweed mechanics): Rocking chair wire acts by the intru-
eruption does not exceed the relative rate of vertical condy-
sion of anterior teeth, extrusion of posterior teeth and pro-
lar growth, there should be no backward mandibular rotation
clination of anterior teeth. A study by Clifford et al. (1999)
(McDowell & Baker, 1991). Bacceti et al. 2012 found that us-
showed that with rocking chair wires, the second molars in-
ing URA at early permanent dentition results in a significant
trude rather than extrude. It is essential to consider the side
and faster reduction in overbite than in the mixed dentition.
effects of rocking chair wire such as distobuccal molar rota-
Simons and Joondeph in 1973 found that treatment during
tion, buccal rolling, premolar expansion, incisor proclination
early permanent dentition is even more stable.
and possible asymmetric bite opening. Hypothetically, 15 de-
2. Extraoral traction: Cervical pull headgear is a commonly grees of (unwanted) labial crown torque would result from
used extraoral appliance to reduce deep overbite. J hooks are leaving a curve of Spee of 5 mm at its greatest depth to go
associated with a high risk of cause root resorption (Linge completely passive.
and Linge 1983). Degushi 2008 compared TAD with J hook
Methods to reduce the unwanted labial tipping of lower in-
for intrusion and found the result is 3.1 and 1.3mm, respec-
cisors during levelling
tively. Alternatively,
These include:
3. Dahl appliance: The Dahl concept involves an anterior
bite-opening appliance in adults to increase the inter-occlu- • A lower incisor prescription with lingual crown
sal distance and allow the intrusion of teeth in contact with torque.
the appliance (usually anterior teeth) and extrusion of those
• A lingual crown torque is built in the rectangular
unopposed (posterior teeth). It is beneficial in cases of tooth
wire.
surface loss, where an increase in the occlusal vertical dimen-
sion is required to produce enough space for a definitive res- • An intra-arch space to allow traction and counteract
toration (Cobourne and DiBiase, 2015, Björk, 1969). proclination.
4. Appliance selection: Begg and Tip edge appliances are ef- • Class 3 elastic may cause unwanted anchorage loss
ficient in deep bite reduction. With lingual appliances, verti- in the upper arch.
cal control is clinically more efficient than conventional labial
8. Auxiliary appliances such as:
appliances because of the ribbon-wise slot configuration and
the proximity of the force applied to the centre of rotation • Fixed anterior bite turbo.
and root, in addition to the anterior bite effect of the lingual
• Class 2 bite corrector.
appliance.
• Class II inter-maxillary elastics
5. Fixed appliance settings such as:
9. Auxiliary archwires such as:
• Hybrid bracket positioning and variation (Hold-
away, 1952). • The “HG-tandem”: The “HG-tandem” mechanics
in the maxillary arch consisted of a 2 x 4 lever arch,
• Partial ligation of the distally inclined canines to
cinched back, and gabled 1 mm anterior to the mo-
avoid overbite deepening.
lar band. It achieved around 1.9 mm of true incisor
• Avoid using laceback or cinch back to allow the arch intrusion (Hans 1994)
to lengthen.
• Anchor bend approach: It is used during the first
DEEP BITE 201

stage of the Begg technique and is most useful for a these bypass arches depends on the forces being light. Two
patient with some growth. Mulligan (1980) advocat- weaknesses of the bypass arch systems limit the amount of
ed a similar approach using the edgewise appliance. true intrusion that can be obtained (a) extrusion of the first
molar can occur through distal tipping of molars. Hence,
• Auxiliary levelling arch: it is made from 17 × 25 mil
high-pull headgear may be used, especially in non-growing
TMA wire, inserted into the auxiliary tube on the
patients, (b) the intrusive force against the incisors is applied
molar and tied anteriorly beneath the 0.018 SS base
anterior to the centre of resistance which pushes the incisors
arch.
to tip forwards as they intrude.
• Connecticut intrusion: in this technique, the brack-
Advantages of segmental archwires technique
ets of the 4 maxillary incisors are laced-back. A pas-
sive 0.016-in round segmental archwire is placed on These include:
maintaining the initial position of the 4 maxillary
• A long-range of action, because of the long inter-
incisors. A 0.016x0.022-in long NiTi intrusion arch
bracket span
is tied below the lateral incisor brackets and cinched
back to prevent facial tipping of the incisors (Nanda • More easily estimated biomechanical effects
1998).
• Frictionless
10. Segmental archwire techniques such as:
Disadvantages of segmental mechanics
A. Burstone archwires mechanics: In this technique, the buc-
These include:
cal segments are first aligned and then stabilised using a full
dimension rectangular archwire, the same for the anterior • Complexity of fabrication
segment. In addition to this, a heavy lingual arch is used to • Poorer control of overall arch form
connect the right and left posterior segments. An auxiliary
depressing arch is then placed in the auxiliary tube on the • Less ‘fail-safe’ effect if the case is unsupervised for a
first molar and is used to apply force against the anterior seg- period
ment. It is recommended that no more than the four inci- • Oral hygiene difficulties and patient discomfort if
sors be incorporated in the intrusive segment. If the canines the wires impinge on the mucosa.
were also included, the anchorage balance would shift unac-
ceptably towards distal tipping of the buccal segment teeth. • Proclination and wagon wheel effect
Burstone recommends that the dimension of the wire be 11. Absolute anchorage: This can be delivered using os-
.018x.025ss wire with a two and a half turn helix, alternative- seointegrated implants, onplants or miniscrews (TADs).
ly, .019x.025 TMA without a helix can be used. When passive, Degushi in 2008 compared TAD with J hook for intrusion
the wire should lie just gingival to the incisor teeth and apply and found the result is 3.1 and 1.3mm, respectively. A study
a light force of 10-15g when activated. The Burstone intrusion by Aras and Tuncer 2016 compared using TADs directly to
arch is tied beneath the brackets, not into the bracket slots intrude the posterior teeth or placing the TADs posteriorly
occupied by the anterior segment wire. It still has the effect of to support an intrusion archwire. They found that intrusion
wanting to tip the incisors forward as they intrude, but two anchoring from posterior mini-implants is preferred in cases
strategies may be employed to prevent this: (a) the archwire of upright incisors.
may be tied back against the posterior segment. However, this
can strain the posterior anchorage, (b) the point of force ap- 12. Surgical treatment of the Deep Overbite: In case of
plication may be altered by tying it more distally. It is feasible an increased lower facial height, moderate curve of spee is
to intrude asymmetrically, which requires only adjusting the corrected by true intrusion of incisors, however, surgery may
teeth placed in stabilising and intrusion segments and tying involve lower anterior dentoalveolar stepdown and BSSO ad-
the auxiliary intrusion arch in the area where the intrusion is vancement. In case of a reduced lower facial height, surgery
necessary. If an intrusion is desired only on one side, either may involve 3 point landing BSSO advancement.
a cantilevered auxiliary wire extending from one molar or a Effectiveness of different approaches
molar-to-molar auxiliary arch can be used. The key is tying
the auxiliary arch at the point where the intrusion is desired. Investigations comparing reverse curves of Spee archwire
(modified Tweed technique) to Burstone mechanics for over-
B. Rickett’s utility arch: The utility arch is characterised by bite reduction: Weiland 1996, found no significant difference
step-down bends between the first molar and the lateral in- between Burstone mechanics and modified Tweed mechan-
cisors, and it is constructed in .016” square Elgiloy. In most ics as a result of the overbite correction. However, Burstone
cases, the archwire is placed into the brackets with slight la- mechanics results in more incisor intrusion while Tweed
bial root torque to control the inclination of the teeth as the mechanics produces minimal intrusion and a high amount
incisors move labially while they intrude. Success in using of molar extrusion. Ng 2005 systematic review showed that
202 DEEP BITE

the segmented arch technique in no growing patients has 1.5 •
Counterforce or rocking chair NiTi archwires
mm of maxillary incisor intrusion and 1.9 mm of mandibular (Modified Tweed mechanics)
incisor intrusion.
• Auxiliary appliances
Investigations comparing reverse curves of Spee AW (modi-
• Auxiliary archwires
fied Tweed technique) to sectional arches for overbite reduc-
tion (Rickett utility arch): Dake & Sinclair in 1989 showed • Segmental archwire technique
that Ricketts and Tweed-type arch levelling techniques were
• Absolute anchorage
successful in overbite correction with minimal increases in
mandibular plane angle and anterior facial height noted. They • Surgical treatment of the Deep Overbite
also found mandibular incisors procline more in the Ricketts
group with a greater post-treatment uprighting and overbite
relapse than in the Tweed group.
References
Exam night review dontics, Elsevier Health Sciences.
Deep bite represents a condition when the maxillary incisors HOLDAWAY, R. A. 1952. Bracket angulation as applied to the
overlap the mandibular incisor crowns vertically by greater edgewise appliance. The Angle Orthodontist, 22, 227-236.
than one-half of the lower incisor crown height. Worldwide, HOUSTON, W. J. B. 1989. Incisor edge-centroid relationships and
the prevalence is 11.13 % in mixed dentition and 14.98% in overbite depth. European Journal of Orthodontics, 11, 139-143.
the permanent dentition (Alhammadi, 2018).
Aetiology deep overbite morphology and activity of the masticatory muscles. J Oral Reha-
bil, 1, 131-47.
• Skeletal and growth factors (Pancherz et al., 1997)
KIM, Y. H. 1974. Overbite depth indicator with particular refer-
• Soft tissues factors (Nicole 1954, Ridley 1960) ence to anterior open-bite. American Journal of Orthodontics and
• Dental factors (McIntyre and Millett, 2003)
Principles of deep incisor overbite reduction SON, P., WILLIAMS, A. & DE OLIVEIRA, C. M. 2006. Orthodon-
• True incisor intrusion tic treatment for deep bite and retroclined upper front teeth in
children. Cochrane Database Syst Rev, Cd005972.
• Levelling of the arch (Cobourne and DiBiase, 2015).
NAHOUM, H. I. 1977. Vertical proportions: a guide for prognosis
• Incisor proclination or relative incisor intrusion and treatment in anterior open-bite. Am J Orthod, 72, 128-46.
(Ireland et al., 2016). NAINI, F. B., GILL, D. S., SHARMA, A. & TREDWIN, C. 2006.
• Distal tipping of posterior teeth The aetiology, diagnosis and management of deep overbite. Dent
Update, 33, 326-8, 330-2, 334-6.
• Surgery to change the anteroposterior and vertical
NIELSEN, I. L. 1991. Vertical malocclusions: etiology, develop-
relationship.
ment, diagnosis and some aspects of treatment. Angle Orthod, 61,
Management of overbite 247-60.
• Upper removable appliance (URA) (Millett et al., PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
2006). temporary orthodontics, Elsevier Health Sciences.
• Extraoral traction (Linge and Linge 1983). SKIELLER, V., BJORK, A. & LINDE-HANSEN, T. 1984. Predic-
tion of mandibular growth rotation evaluated from a longitudinal
•
Dahl appliance (Cobourne and DiBiase, 2015, implant sample. Am J Orthod, 86, 359-70.
Björk, 1969).
• Appliance selection
• Fixed appliance settings
• Continuous rigid archwires
DEEP BITE 203

204 DEEP BITE
Low Angle 205
20
Low Angle Cases
In this Chapter
1. Aetiology and profile
2. Features of low angle cases
3. Predictors of low angle
4. Principals of treatment
5. Methods to reduce overbite
6. The Dahl concept
T he decreased vertical proportion (short face) charac-
Predictors of low angle
These include Bjork’s 7 structural signs that identify low angle
terised by deep bite is called low angle. In a cephalometric
analysis of a low angle patient, the majority of ceph values are cases (Björk, 1969):
lower from standard deviation: • Decreased lower AFH.
• Maxillary mandibular plane angle (MMPA) lesser • Increased intermolar and interpremolar angle.
than 21.
• Increased interincisal angle.
• Frankfort mandibular plane angle (FMPA)lesser
• Forward inclination of the mental symphysis.
than 22.
• Forward inclination of the condylar head.
• SN-mandibular plane lesser than 28˚.
• The curvature of the mandibular canal is greater
• SN-palatal plane lesser than 5˚.
than the mandibular contour.
• MMA angle is greater than 29˚.
• The lower mandibular border is rounded anteriorly,
• Y-axis angle lesser than 62˚. concave at the angle, and has an absent antegonial
• Jarabak ratio is greater than 64%. notch.
• Sum of inner angles less than 392˚. Principals of treatment
• Individuals of the short face type are characterised These include:

by short anterior lower face height (also known as • True incisor intrusion.
hypodivergent).
• Posterior extrusion in a growing patient (Cobourne
Aetiology of low angle cases and DiBiase, 2015)
The main aetiology is the forward growth rotation (average • Incisor proclination or relative incisor intrusion.
is -7°) (Bjork and Skieller, 1972). The forward growth rota- (Ireland et al., 2016).
tion has been thought due to an increase in the normal inter-
• Backward rotation of the mandible.
nal rotation and a decrease in the external rotation (Nanda,
1990). In adults no compensatory growth; therefore, posterior ex-
trusion treatment is considered unstable. Adult orthodontic
Features of low angle cases
treatment is consequently restricted to incisor intrusion or
These include: proclination.
1. Skeletal features such as a short square-shaped face, low Methods to reduce overbite
vertical proportions, Class II skeletal relationship
Removable appliances such as:
• Upper removable appliance with anterior bite plane.
• Hypertrophic mentalis and masseters (type II col-
• Low pull headgear.
lagen fibers) (Hunt et al., 2006).
• Dahl appliance.
• Skin folds can be seen lateral to oral commissure.
• Functional appliances.
• Acute labiomental and nasolabial angles.
Fixed Appliances such as:
• Prominent chin
• Upper fixed bite plane (bite turbo).
• Increased incisor show on rest and smile.
• Lingual brackets. Lingual brackets act as a bite plane.
3. Dental features such as:
• Begg or Tip-Edge appliances.
• The overbite can be increased and complete with
or without palatal trauma (Ingervall and Thilander, • Lower archwire with the reverse curve of Spee.
1974).
• Upper archwire with an increased curve of Spee.
• Lower incisors are typically proclined and crowded.
• Intrusion arches, i.e. Rickets & Burstones utility
• The upper arch is broad, and the palatal vault is flat arch.
often.
• Intermaxillary elastics.
• Large interocclusal space.
Low Angle 207

• Incorporation of 2nd molars may extrude first mo- • Curvature of the mandibular canal is greater than
lars and second premolars (Eberhart et al., 1990). the mandibular contour.
• Anchor bends to flare labial segment and distal tip • Absence of antegonial notch.
posterior teeth.
Treatment options
• TADs to intrude incisors and extrude the molars
• Posterior extrusion.
(Clifford et al., 1999).
• Incisor intrusion.
• Combined orthodontic-surgical approach.
• Incisor proclination.
The Dahl concept
• Backward rotation of the mandible.
The Dahl concept involves an anterior bite-opening appliance
in adults to increase the inter-occlusal distance and allow the Method to reduce overbite
intrusion of teeth in contact with the appliance (usually an-
• Upper removable appliance with anterior bite plane/
terior teeth) and extrusion of those unopposed (posterior
turbos.
teeth). It is beneficial in cases of tooth surface loss, where an
increase in the occlusal vertical dimension is required to pro- • Upper fixed bite plane (bite turbo).
duce enough space for a definitive restoration (Cobourne and
• Low pull headgear.
DiBiase, 2015, Björk, 1969).
• Dahl appliance.
• Functional appliances.
• Lingual brackets.
• Begg or Tip-Edge appliances.
• Lower archwire with the reverse curve of Spee.
• Upper archwire with an increased curve of Spee.
• Segmental archwires or intrusion arches, i.e. Rickets
Exam night review & Burstones utility arch.
Features of low angle cases • Intermaxillary elastics.
• Short square-shaped face. • Banding/bonding of 2nd molars can also be done to
• Hypertrophic masseters (type II collagen fibers) extrude first molars and second premolars (Eberhart
(Hunt et al., 2006). et al., 1990).
• Skin folds can be seen lateral to oral commissure. • Anchor bends.
• Reduced incisor show on a smile. • TADs (Clifford et al., 1999).
• Deep overbite (Ingervall and Thilander, 1974). • Combined orthodontic-surgical approach.
• Lower incisors are typically proclined and crowded.

• The upper arch is broad, and the palatal vault is flat
often.
• Increased interocclusal space.
Bjork’s 7 structural signs of low angle (Björk, 1969)
• Increased intermolar and interpremolar angle.
• Increased interincisal angle.
• Decreased lower AFH.
• Forward inclination of mental symphysis with a
prominent chin.
• Forward inclination of the condylar head.
208 Low Angle

References
BJO¨RK, A. & SKIELLER, V. 1972. Facial development and tooth
eruption: An implant study at the age of puberty. American Journal
BJÖRK, A. 1969. Prediction of mandibular growth rotation. Ameri-
can Journal of Orthodontics, 55, 585-599.
CLIFFORD, P. M., ORR, J. F. & BURDEN, D. J. 1999. The effects of
increasing the reverse curve of Spee in a lower archwire examined
using a dynamic photo-elastic gelatine model. Eur J Orthod, 21,
213-22.
EBERHART, B. B., KUFTINEC, M. M. & BAKER, I. M. 1990. The
relationship between bite depth and incisor angular change. Angle
Orthod, 60, 55-8.
HUNT, N., SHAH, R., SINANAN, A. & LEWIS, M. 2006. North-
croft Memorial Lecture 2005: muscling in on malocclusions: cur-
rent concepts on the role of muscles in the aetiology and treatment
of malocclusion. J Orthod, 33, 187-97.
morphology and activity of the masticatory muscles. J Oral Reha-
bil, 1, 131-47.
IRELAND, A. J., SONGRA, G., CLOVER, M., ATACK, N. E.,
SHERRIFF, M. & SANDY, J. R. 2016. Effect of gender and Frankfort
mandibular plane angle on orthodontic space closure: a random-
ized controlled trial. Orthod Craniofac Res, 19, 74-82.
NANDA, S. K. 1990. Growth patterns in subjects with long and
short faces. Am J Orthod Dentofacial Orthop, 98, 247-58.
PROFFIT, W., FIELDS, H. & SARVER, D. 2006. Contemporary
Orthodontics 4th Edition. Mosby, USA, 411.
Low Angle 209

Hypodontia
21
Written by: Mohammed Almuzian, Haris Khan, Maham Batool,Taimoor Khan, Rim Fathalla, Lubna
Almuzian, Dalia El-Bokle
In this Chapter
1. Classification of hypodontia 22. Evidence summary
2. Candidate genes in hypodontia 23. EXAM NIGHT REVIEW
3. Incidence of hypodontia
4. Aetiology and theories of hypodontia
5. Clinical presentation of hypodontia
6. Malocclusion features of hypodontia patients
7. Indications for treatment
8. General treatment principles
9. Options for treatment
10. Auto-transplantation
11. Space closure
12. Problems and solutions of cuspid substitution
13. Benefits of cuspid substitution
14. Points to consider during space closure
15. Reopen or redistribute space
16. Space opening and prosthetic replacement
17. Interim prosthesis of a space of a missing tooth
18. Types of final restorations
19. Criteria for implant placement
20. Success of dental implants
21. Treatment options for absent premolars
210 HYPODONTIA
Hypodontia is the developmental absence of one or more Table 1: Syndromes associates with hypodontia
teeth, excluding third molars (Goodman et al., 1994), also
known as selective tooth agenesis. Syndrome Associated gene(s)
Classification of hypodontia Anhidrotic ectodermal EDA

dysplasia(Visinoni et al.,
These include: 2009)
1. According to the severity of missing teeth (Hobkirk et al., Ehlers–Danlos syndrome ADAMTS2
1995) Incontinentia pigmenti NEMO
• Mild: 1 to 2 missing teeth, also called Hypodontia. Limb mammary TP63
• Moderate: 3 to 6 missing teeth. Reiger syndrome PITX2
• Severe: more than 6 missing teeth. Witkop (Jumlongras et al., MSX1

2001)
Mild forms of hypodontia are more common (81.6%) than Ellis–van Creveld syndrome EVC or EVC2
moderate (14.3%) and severe (3.1%) (Khalaf et al., 2014).
Cleft lip and palate and Van de Wound syndrome
2. According to the number of missing teeth (Hobkirk et
al., 1994) Candidate genes
• Hypodontia: Agenesis of 1-6 teeth excluding third These include:

molars. Generally, MSX1 represents a candidate gene for both syn-
• Oligodontia: Agenesis of more than six teeth, ex- dromic and non-syndromic hypodontia.
cluding the third molars. 1. Candidate genes for non-syndromic hypodontia (Vas-
• Anodontia: complete absence of teeth. tardis et al., 1996, Lammi et al., 2004, Cobourne, 2007b)
are:
3. According to inheritance pattern
• MSX1 and MSX2: they are expressed in regions of
A. Non-syndromic: It can be sub-classified according to the condensing mesenchyme of tooth germ and associ-
method of occurrence (Burzynski and Escobar, 1983). ated with premolars and lateral incisors and some-
• Sporadic hypodontia: This involves 33% of hy- time associated with severe hypodontia.
podontia cases. • EDA gene mutations usually includes the loss of
• Familial or inherited: This form follows autosomal mandibular and/or maxillary incisors and canines.
dominant, autosomal recessive or autosomal sex- • PAX9 is a transcription factor during tooth mor-
linked patterns of inheritance, with considerable phogenesis and is associated with molar hypodontia.
variation in both penetrance and expressivity.
• AXIN2 is involved in cell growth proliferation and
Non-syndromic hypodontia can also be sub-classified ac- differentiation and it is mainly associated with Finn-
cording to the teeth involved and their numbers: ish family hypodontia.
•
Localized incisor–premolar hypodontia (OMIM Incidence of hypodontia
106600), which affects only one or some of these
teeth. This is the most common form and seen in In summary:
around 8% of Caucasians (Nieminen et al., 1995). 1. Type of dentition: In Caucasians, localized incisor–pre-
•
Oligodontia (OMIM 604625) occurs in around molar hypodontia has been reported to be 8%, whilst oligo-
0.25% of Caucasians and can involve all classes of dontia occurs in around 0.25% (Nieminen et al., 1995, Sarnas
teeth (Sarnas and Rune, 1983). and Rune, 1983). Prevalence of hypodontia is high in Africa
(13.4%), followed by Europe (7%). Asians and Australians
B. Syndromic: Hypodontia can be associated with an un- have a similar prevalence of 6.3%. The lowest prevalence of
derlying genetic disorder. Hypodontia has been reported in 4% was reported in Latin America and the Caribbean (Khalaf
more than 50 syndromes, some of them are given in Table 1. et al., 2014). However, another systematic review and meta-
analysis found no difference in prevalence among popula-
tions of various ethnicities and geographic locations (Rakh-
shan and Rakhshan, 2016).
2. Ethnicity variation: In Caucasians, localized incisor–pre-
molar hypodontia has been reported to be 8%, whist oligo-
HYPODONTIA 211
dontia occurs in around 0.25% (Nieminen et al., 1995, Sarnas als (Zilberman et al., 1990). Diminutive laterals are
and Rune, 1983). Prevalence of hypodontia is high in Africa often present in cases of palatally impacted canines
13.4% followed by Europe 7%. Asian and Australians have (Brin et al., 1986). A meta-analysis found that pa-
a similar prevalence at 6.3%. The lowest prevalence of 4% tients with unilateral diminutive shaped incisors
was reported in Latin America and Caribbean (Khalaf et al., have a high chance of agenesis (55%) of the lateral
2014). However, another systematic review and meta-anal- incisor on the opposing side (Hua et al., 2013).
ysis found no difference in prevalence among population of
• Lower incisors more commonly absent in the Asian
various ethnicities and geographic location (Rakhshan and
population, whilst the incidence among Caucasians
Rakhshan, 2016). In the UK population, the incidence of hy-
is 0.2% (J Neal and E Bowden, 1988).
podontia is 5.3-5.6% (Polder et al., 2004).
In Caucasians, the most commonly missing teeth after third
3. Gender variation: Hypodontia is more frequently report-
molars are lower second premolars > upper lateral incisors >
ed in females (Fekonja, 2005b, Khalaf et al., 2014). Females
upper second premolars > lower central incisors (Larmour et
to male ratio has been reported as F:M = 3:2 (Larmour et al.,
al., 2005). In some Asian populations, lower central incisors
2005, Rolling, 1980). The incidence in males is 4.6%, and in
are reported to be commonly missing.
females 6.4% (Polder et al., 2004).
Aetiology and theories of hypodontia
4. Jaw and side of occurrence: Increased incidence of miss-
ing teeth has also been reported in the maxilla (Sisman et al., A series of molecular regulatory factors and pathways are in-
2007) and in the mandible (Kirzioglu et al., 2005, Rolling, volved in tooth development. Factors such as FGF, BMP and
1980). No difference in right or left side predilection has been Wnt signaling pathway take part in epithelial-mesenchymal
found (Sisman et al., 2007), but some studies reported an in- interactions that are required for normal development of
creased incidence on the left side (Wisth et al., 1974, Roll- teeth. Any disturbance in these pathways may lead to tooth
ing, 1980), while others found a right sided predominance agenesis (Zhu et al., 1996). Several theories have been pro-
(Fekonja, 2005b). posed including:
5. Unilateral vs bilateral hypodontia: Overall, unilateral 1. Evolutional theory: Evolution of humans has resulted in a
missing teeth are more common, however, upper lateral in- decrease in size of jaws and number of teeth present in these
cisors are more commonly missing bilaterally (Chung et jaws (Vastardis, 2000). Generally, mesial teeth are more de-
al.,2008, Polder et al.,2004). Unilateral missing teeth are more velopmentally stable than teeth at distal end of series (Hob-
common in the case of the upper and lower second premolars kirk et al., 2010)
(Polder et al.,2004)
2. Anatomical theory: Dental lamina of teeth that are pres-
6. Sequence of hypodontia: Teeth that are present at the end ent at fusion regions of jaw bones or embryological processes
of each series are more susceptible to agenesis. It has been (Al-Ani et al., 2017a), are more susceptible to environmental
hypothesized that terminal teeth form at last in each tooth defects (Svinhufvud et al., 1988). Another theory is that the
series; thus, they can fall below the threshold that is required areas which developed at a later stage are more susceptible to
for normal dental development (Thesleff, 1996). Mesial teeth tooth developmental disturbances (Kjær et al., 1994).
are more developmentally stable than teeth at the distal end
3. Environmental theory includes (Al-Ani et al., 2017b):
of a series (Hobkirk et al., 2010). Some believe that these teeth
develop from two embryological origins, hence, they are at i. Systemic disruption of dental lamina by:
high risk of being missing (Al-Ani et al., 2017a). In summary: • Chemotherapy and radiotherapy in infancy (Parkin
• Third molars are the most commonly absent teeth et al., 2009, Näsman et al., 1997).
with an incidence of 25-35% (Peck et al., 1996). • Infection e.g. rubella infection (Cameron and Samp-
• Premolars can form as late as 9 years of age. Lower son, 1996).
5s are the most commonly absent (2.6%), followed • Drug interaction e.g. thalidomide (Gilbert-Barness,
by upper 5s then 4s (Wisth et al., 1974). Peck has re- 2010).
ported a 3% incidence of missing second premolars
(Peck et al., 1996). • Toxin (Brook, 2009)
• Canines, first and second molars are rarely missing ii. Localised disruption of dental lamina by:
(Symons et al., 1993) • Trauma, such as fracture of alveolar process (Brook,
• Absent maxillary lateral incisors occur in 2% of the 2009)
population (Peck et al., 1996). Familial tendency has • Cleft of alveolus resulting in transection of dental
been found for both diminutive and missing later- lamina
212 HYPODONTIA
• Nutritional deprivation e.g. insufficient calcium in • Upright incisors
diet.
• Generalized spacing and rotation of teeth adjacent
4. Genetic factors: Polygenic multifactorial model of aetiol- to the missing teeth.
ogy has been proposed as an aetiology for hypodontia, with
• Over-erupted incisors
many studies reporting a strong influence of genetic factors
on hypodontia. Twin studies demonstrated the autosomal • Increased overbite
dominant inheritance with incomplete penetrance and vari-
D. Dental features such as:
able level of expressivity (Cobourne, 2007a). Non-syndromic
hypodontia has a variable mode of inheritance, and can be • Enamel hypoplasia
autosomal dominant, autosomal recessive or autosomal sex • Microdontia (Graber, 1978) or conical / reduced
linked (Cobourne et al., 2012). Almost 300 genes are involved crown morphology of permanent teeth present
in the development of the dentition. Some of the genes most (Brook, 1984)
frequently associated with non-syndromic hypodontia are
presented in table 1. • Molar taurodontism
Clinical presentation of hypodontia • Short rooted teeth.
Clinically, patients with hypodontia may present with (Gill • Absent primary tooth
and Barker, 2015): • Prolonged retention of primary teeth (Kurol and
• Retained primary teeth, Thilander, 1984).
• Infra-occluded primary teeth, • Ankylosed primary teeth,
• Ankylosed primary teeth, • Infra-occlusion of primary teeth (Kurol and Thilan-
der, 1984).
• Absent primary tooth,
• Ectopic eruption or impaction of the adjacent teeth,
• Delayed / asymmetric eruption of permanent teeth, particularly maxillary canines. Up to 5% of those
• Conical / reduced crown morphology of permanent with absent lateral incisors may present with maxil-
teeth present, and lary canine impaction. (Brin et al., 1986)
• Lack of alveolar bone growth in three planes of • Transposition (Peck et al., 1996)
space. • Delayed and asymmetric eruption of permanent
Malocclusion features of hypodontia patients teeth. The second premolars are particularly prone
to a delay in dental development, and may not be
The dental, occlusal, alveolar and skeletal features of patients
visible radiographically until the age of 9 years.
with hypodontia include:
Hence, a diagnosis of their absence should be made
A. Skeletal features (depending on the severity of maloc- with caution before this age. (Wisth et al., 1974)
clusion) such as:
• Lack of alveolar bone growth in three planes of
• Retrognathic and hypoplastic maxilla (Wisth et al., space.
1974, Hobkirk et al., 1995).
Indications for treatment
• Reduced MMPA and reduced vertical dimensions.
Several indications were proposed for treating hypodontia
(Taju et al., 2018).
including (Shaw et al., 1980):
• Low mandibular plane angle associated with re-
• Functional needs: Hypodontia has an adverse im-
duced lower anterior facial height and protrusive
pact on quality of life measures (Akram et al., 2011,
lips (Chung et al., 2000).
Akram et al., 2013, Wong et al., 2006)
B. Alveolar features (Cobourne and DiBiase, 2015) such
• Aesthetic needs
as:
• Dental health problems including food impaction
• Lack of alveolar bone
due to tipped or drifted teeth, traumatic over bite
• Fairly flat palatal vault which results in reduced and infraoccluded primary teeth
anchorage capacity of upper removable appliances,
General treatment principles
Nance palatal arch or implant placement.
Inter-disciplinary treatment involving orthodontist, prosth-
C. Occlusal features (Fekonja, 2005b) such as:
HYPODONTIA 213
odontist, oral surgeon and restorative dentist is necessary sor (U1) and canine (U3). Commonly, restorative
(Stevenson et al., 2013, Hobkirk et al., 2010), taking into con- dentists prefer to have more space between U2 and
sideration several factors such as: U3.
A. Complications /difficulties with treatment: The follow- • Where should U2 be positioned bucco-lingually: to-
ing complications are encountered while treating cases with ward the labial, in the centre of the ridge, or toward
hypodontia (Grahnén, 1956b): the lingual? Depend on the type and thickness of fi-
nal restoration.
• Aesthetic impact of treatment
• Where should U2 be positioned inciso-gingivally?
• Increased overall cost of treatment
This relationship is determined by the position of
• Increased treatment time the gingival margins.
• Anchorage difficulties 4. Evaluate gingival aesthetics.
• Poor root parallelism for implants 5. Determine space required by golden proportion, universal
mesio-distal width, contra lateral-tooth size or Bolton analy-
• Risk of relapse e.g. spaces reopening
sis (Bolton, 1958).
• Atrophy and loss of bone
6. Provision of space to facilitate restorative treatment.
• Compromised treatment outcome: Common issues
7. Take progress radiographs, and measure the space with
faced in treating these patients include space man-
the implant T ruler.
agement, uprighting and aligning teeth, manage-
ment of the deep overbite, and retention (Carter et 8. Occlusal adjustment.
al., 2003).
9. Interact with restorative dentists during finishing.
B. Treatment factors: The following factors should be con-
Options for treatment
sidered (Hobkirk et al., 1995):
These include (Gill and Barker, 2015):
• Age
A. No active treatment: No treatment is necessary if there is
• Medical history
no malocclusion associated and the patient is satisfied with
• Patient’s opinion and co-operation his/her dentition, or unwilling to commit to lengthy and
costly treatment (Kokich and Kinzer, 2005).
• Facial profile
B. Interceptive treatment: General dentists play an important
• Smile line
role in early detection of developmentally missing incisors.
• Gingival line Early extraction of primary canine to prevent / intercept
• Malocclusion and extent of hypodontia the associated impaction of the maxillary canine has been
advocated in many studies (Parkin et al., 2017). Intercep-
• Intra- and inter-arch relationships tive extractions of primary teeth are advised in the mixed
• Dental features size, shape, colour of the adjacent dentition stage for maximum space to be closed spontane-
teeth ously (Lindqvist, 1980), maintaining alveolar bone for future
implant placement (Kokich et al., 2011, Fekonja, 2005a).
• Clinical situation of retained teeth. However, retention of the primary incisor or canine can be
C. Sequence of treatment of functional benefit as the primary teeth will maintain the
alveolar bone for orthodontic treatment and future implant
Both orthodontists and restorative dentists should estab- placement (Carter et al., 2003).
lish realistic objectives rather than idealistic, which include
(Spear et al., 1997): C. Auto-transplantation: It can be recommended if a donor
premolar is available, to transplant to the recipient (hy-
1. Create a diagnostic set-up (set up of current dentition) or podontia) site, especially in cases of multiple missing maxil-
Kesling set up (repositioning of dentition). lary incisors (Zachrisson et al,2004). Criteria for auto-trans-
2. Determine the sequence of orthodontic treatment. plantation of premolars to missing incisors site (Andreasen
et al., 1990b) are:
3. Building-up malformed teeth and answering the follow-
ing questions: • Roots of the donor premolars should be less than ¾
formed.
• Where should the maxillary lateral incisor (U2) be
positioned mesiodistally relative to the central inci- • Multiple missing incisors.
214 HYPODONTIA
• Procedure is undertaken by skilled surgeons. Problems and solutions of cuspid substitution
• Adequate space in the arch (Zachrisson et al., 2004). Although cuspid substitution offers several advantages over
space opening, it is associated with some obstacles (Table 3).
• No jiggling contacts between donor tooth and op-
posing teeth during post-surgical recovery phase Benefits of cuspid substitution
(Andreasen et al., 1990a).
These include:
• Use of 3D printed donor tooth to facilitate surgical
• Cuspid substitution is considered the least invasive
procedure.
option when compared to tooth-supported restora-
Advantages of auto-transplantation (Aslan et al., 2010) tions or implant replacement.
These include: • Evidence has shown that implant-supported re-
placement is not immune to complications such as
• In growing children, the transplanted tooth main-
progressive resorption of the labial cortical plate,
tains growth and development of the alveolar ridge,
progressive infraocclusion secondary to long-term
and also provides a permanent solution to agenesis
facial growth, gingival darkening, gingival recession
of teeth.
as well as the possible need for several years of post-
Successfully transplanted premolars appear to treatment maintenance and probably bone augmen-
continue erupting and aesthetics is good when restored with tation (Thilander, 2000, Robertsson and Mohlin,
porcelain veneer crowns or full porcelain coverage. 2000).
D. Space closure: Factors favouring the decision to close the • Also, the difficulty of matching natural tooth color
space when upper lateral incisors are missing are listed in and translucency with an implant-supported pros-
table 2. thesis has been reported (Zachrisson et al., 2004,
Kokich and Kinzer, 2005).
Table 2: Factors favouring the decision to close the space of missing upper lateral incisor
Factors Examples
General factors Patients willing to undergo a possibly longer treatment duration and enameloplasty of the canine
and premolar.
Patients refusing artificial teeth/prosthetic restorations; bridges or partial denture, or implants.
Macro-aesthetic factors Convex facial profile or Class II skeletal and dental relationships.
Bimaxillary protrusion requiring extraction for profile improvement.
Class II malocclusion with redundant overjet.
Mini-aesthetic factors Normal or increased tooth-gingival display during smiling.
Micro-aesthetic factors Small or average sized canine.
Favorable light color of canine.
Adequate attached gingiva on the canine.
Optimum alveolar bone width for canine mesialization.
Intra- and inter-maxillary Bilateral absence of lateral incisors.
factors
Unilateral agenesis of lateral incisor with a contralateral peg-shaped tooth.
Crowding requiring lower premolar extraction.
Minimal space left for the missing lateral incisors.
Proclined or normally-inclined upper incisors.
HYPODONTIA 215
Table 3: List of potential problems and solutions during canine substitution
Problems Solutions
Size mismatch due to large substituting canines and small premolars. Selective reduction and/or addition
Occlusal interference of the upper canine’s cingulum and the upper
premolar’s palatal cusp with opposing teeth.
Interarch tooth size discrepancy
Lack of canine eminence Hybrid bracket prescription
Lack of root parallelism between the adjacent teeth subsequent to Wire bending and detailing
space closure
Root resorption subsequent to the contact between the buccal roots
of the premolars and the buccal cortical bone
Improper gingival margin levels of the canines and premolars Hybrid bracket positioning
Wire bending and detailing
Gingivoplasty
Space reopening (relapse) Long-term bonded retainer
Extending retainer from first premolar to first premolar
and supplement with a removable night time retainer
(Zachrisson et al., 2011)
Dark color of the canine Vital bleaching
Thin porcelain veneer
High anterior anchorage demand, especially in Class III cases Protraction facemask
Profile flattening due to excessive uprighting of upper incisors during Temporary anchorage devices either alone or as part
space closure of an auxiliary appliance system such as Benefit system
(Wilmes et al., 2015, Amm et al., 2019)
Hybrid bracket prescription
Pulp sensitivity/exposure due to reshaping Adequate cooling & incremental reduction
Fluoride varnish for sensitivity
• It has been proven that the alveolar bone height can *Compensated bracket positioning for space closure treat-
be preserved through the early mesial movement of ment option
the canine (Zachrisson, 2007) with a minimal det- These include:
rimental effect on occlusal function (Nordquist and
McNeill, 1975). Compensated occlusal-gingival position of brack-
• Not only can cuspid substitution avoid possible im- ets: Two factors affect the choice for vertical canine and
plant failures and complications, but it can also re- premolar bracket positioning in canine substitution cases;
duce treatment time and cost with higher patient these are the lip line and the gingival condition (biotype &
probing depth). In cases of a high upper lip line or gummy
• satisfaction compared to prosthetic replacement
smile, the canine can be bonded more gingival to allow its
(Robertsson and Mohlin, 2000).
extrusion, bringing its gingival margin 0.5mm incisal to the
• According to Schneider et al. (Schneider et al., upper central’s, and its reduced incisal edge 0.5-1mm cervi-
2016), orthodontists and dentists rank cuspid sub- cal to that of the central. The first premolar can be bonded
stitution and implant-supported replacement as as usual occlusogingivally. A gingivectomy or surgical crown
equally pleasing esthetically, while laypeople prefer lengthening is performed to simulate the longer cuspid
canine substitution (Kokich and Kinzer, 2005). crown and provide ideal gingival aesthetics of high, low,
high from central incisors to canine, respectively (Zachris-
son, 2007).
216 HYPODONTIA
Canine and premolar brackets prescription for space closure treatment option
Options for Canines
Bracket* (Torque ˚ / Tip˚) Advantages Disadvantages
Ipsilateral U1 bracket 1. Adequate palatal root torque. 1. Labial enameloplasty is required
OTT=ETT (+17˚/+4o)
2. Suitable if no mesialization is required. 2. Labial offset bend may be required to compensate for
reduced first order depth.
3. Good control of tip and rotation due to wide
bracket 3. Reduced interbracket span; stiffer wire during level-
ing.
4. Unsuitable tip if canine requires mesialization
Swapped U1 bracket 1. Adequate palatal root torque 1. Labial enameloplasty is required
2. Suitable for moderate bodily mesialization 2. Labial offset bend may be required to compensate for
reduced first order depth.
OTT=ETT (+17˚/-4o) 3. Wide; good rotation & tip control during slid-
ing due to a reduced contact angle. 3. Reduced interbracket span; stiffer wire during level-
ing.
Ipsilateral U2 bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
2. Adequate crown tip if no mesial movement is 2. Labial enameloplasty is required.
required.
OTT=ETT (+10˚/ +8˚) 3. Unsuitable if canine requires mesialization.
3. Adequate bracket offset
Swapped U2 bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
OTT (+10˚/ +8˚) 2. Adequate crown tip if significant mesialization 2. Labial enameloplasty is required.
is required.
ETT (+10˚/ -8˚)
3. Adequate bracket offset
Inverted ipsilateral U3 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bracket bonding
2. Unsuitable for canine requiring mesialization.
OTT (-7o /+8o) 2. Adequate tip if no mesial movement is re-
quired.
ETT (+7o /+8o)
Inverted contralateral 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
“swapped” U3 bracket bonding
OTT (-7o /+8o) 2. Adequate tip if significant mesial movement is
required.
ETT (+7o /-8o)
3. The integral hook can be used during mesial-
ization
Inverted ipsilateral U4/5 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bracket bonding.
2. Unsuitable tip for canine requiring mesialization or
OTT (-7˚/0˚) 2. The integral hook can be used during mesial- none.
ization
ETT (+7˚/0˚)
Ipsilateral L3 brackets 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bonding
OTT (-6˚/ +3˚) 2. Unsuitable for canine requiring significant mesializa-
2. Adequate tip if slight mesial movement is tion or none.
ETT (+6˚/-3˚)
required.
Contralteral L3 bracket 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bonding
OTT (-6˚/+3˚) 2. Unsuitable for canine requiring significant mesializa-
tion or none.
ETT (+6˚/+3˚)
HYPODONTIA 217
Ipsilateral L4s bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
2. Adequate tip if slight mesial movement is 2. Unsuitable for canine requiring significant mesializa-
required. tion or none.
OTT (-12˚/+2˚)
3. Labial enameloplasty is not required before
ETT (+12˚/-2˚)
bonding
Ipsilateral L5s brackets 1. Adequate palatal root torque

OTT (-17˚/+2˚) 2. Adequate tip if slight mesial movement is
required.
ETT (+17˚/-2˚)
3. Labial enameloplasty is not required before
bonding
Contralateral L4 bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
OTT (-12˚/+2˚) 2. Labial enameloplasty is not required before 2. Unsuitable tip for canine requiring mesialization or
bonding none.
ETT (+12˚/+2˚)
Contralateral L5 bracket 1. Adequate palatal root torque
OTT (-17˚/+2˚) 2. Labial enameloplasty is not required before
bonding
ETT (+17˚/+2˚)
Options for first premolars
Bracket Advantages Disadvantages
Ipsilateral U3s brackets 1. Adequate buccal root torque 1. Torque is insufficient if premolar requires intrusion
OTT=ETT (-7˚/+8˚) 2. Optimum tip if no mesialization required 2. Tip is unsuitable for mesialization.
Ipsilateral U4s brackets Adequate buccal root torque 1. Torque is insufficient if premolar requires intrusion
OTT=ETT (-7˚/+0˚) 2. Unsuitable tip for premolar requiring mesialization
or not.
Inverted ipsilateral L4s 1. Adequate buccal root for intrusion cases 1. Excessive buccal root torque (risk of root resorption/
brackets fenestration) if premolar is not intruded.
2. Adequate tip if slight mesial movement is
OTT (-12˚/+2˚) required. 2. Insufficient tip if significant mesialisation is required
ETT (-12˚/-2˚)
Original Torque and Tip= OTT, Expressed Torque and Tip=ETT; the Torque and Tip is based on MBT prescription.
**In cases where a bracket with an integral hook is used and inverted, undesirable tipping may be expected during mesialization
because the point of force application is further away from the centre of resistance.
Associated side effects include increased tooth sensitivity, tute the lateral incisors. In this situation, the vertical posi-
regrowth of part of the excised gums, and gingival recession. tion of brackets should be such that after final reshaping,
Suppose the probing depth of the first premolar is normal in the substituted lateral incisors are 0.5 mm shorter than the
the presence of a thin gingival biotype. In that case, it is best substituted central incisors (McDowall et al., 2012).
to bond it more occlusal for intrusion and normalisation of • Compensated mesiodistal position of brackets for
gingival margins. Whereas in case of a low upper lip line or space closure treatment option: If both the canine
lack of gingival margin display, the canine bracket can also and premolar are to be relocated mesially, a slight
be bonded more gingival to bring its reduced incisal edge alteration in mesiodistal bracket position may be
0.5mm cervical to the central incisor’s edge, or normally necessary; this can be achieved through bonding the
if a composite build-up or veneer is planned for. The first be bonded at the same level as the second premolar
premolar should for a group functional occlusion. Another brackets more distally, especially for first premolars
clinical situation is when central incisors are missin g; lateral with divergent roots to prevent the buccal root from
incisors substitute the central incisors, and canines substi- moving into the cortical plate, which may slow down
218 HYPODONTIA
tooth movement and lead to periodontal breakdown tal dimension of the contralateral lateral incisor can also be
and root resorption. This off-set positioning of the used to determine the optimal size of the substituted laterals
premolar bracket also helps move its palatal cusp supplemented with Bolton’s equation and a diagnostic set-up.
distally, reducing cuspal interference and improving
E. Reopen or redistribute space
aesthetic outcomes. Moreover, the upper first molar
tube is positioned more distally to bring the mesial In summary:
cusp inwards for a solid Class II interdigitation if no
• cent teeth (Asher and Lewis, 1986).
extractions are planned in the lower arch.
• Consider retaining the primary teeth for preserving
Compensated axial tip of brackets for space closure treat-
alveolar bone for future placement of implants (Thi-
ment option
lander et al., 1994).
To achieve proper root parallelism at the agenesis site, the
• Before the advances in 3D printing and the use of
axial positions of the canine and premolar brackets may also
skeletal anchorage devices, space opening was rec-
be modified to produce geometry VI forces that allow appro-
ommended in (Paduano et al., 2014):
priate final root approximation.
1. Retruded profiles to improve labial sagittal relationships.

Figure 1: Altering tooth size and shape for optimal canine
substitution 2. Class 3 skeletal cases to prevent reverse overjet.
Camouflaging the size and shape of teeth for space closure 3. Low angle subjects.
treatment option 4. Unilateral tooth agenesis to improve the aesthetics of pa-
Agenesis of maxillary lateral incisors may present with nor- tients and preserve smile symmetry.
mal or under-sized canines (Mirabella et al., 2012, Bozkaya 5. Molar Class 1 or class 3 tendency to preserve ideal oc-
et al., 2018). Therefore, the substituted laterals’ optimal size clusal anterior and posterior relationships (canine and molar
should be evaluated carefully before and during treatment relationships) so that an Angle Class 1 relationship can be
to determine the need for and amount of reduction or ad- obtained.
dition (Figure 1). Several methods are available, such as the
golden proportions in which the lateral incisor’s mesiodistal 6. Reduced overjet.
dimension represents 61.8% of the central incisor (Kokich 7. Increased overbite.
and Kinzer, 2005). Moreover, if not diminutive, the mesiodis-
HYPODONTIA 219
8. Cases with large canines. celain fused to metal bridges (PFB).
• The main disadvantage of space opening is the • The 5 and 10-year survival rate of resin-bonded
commitment of a dental prosthesis throughout life bridges (RBB) is 91% and 83%, respectively though
(Carter et al., 2003). RBBs with zirconia framework or that involving one
tooth showed the greatest survival rate (Thoma et al.,
• The benefits of space opening are:
2017).
1. Good interocclusal interdigitation can be achieved (Balshi,
• Survival of cantilevered RBB is at least as good as a
1993).
fixed design (Spear et al., 1997, Creugers et al., 1992,
2. Some suggest that the space opening approach is func- Hussey and Linden, 1996, Pröbsfer and Henrich,
tionally more stable and Ffaster treatment than space closure, 1997).
but with no string evidence.
• Survival rate of FRCB was 64% after 5 years, irre-
Space opening and prosthetic replacement spective of surface or hybrid retainer. Most failures
were due to fracture of the framework and delami-
Interim prosthesis of a space of a missing tooth
nation (van Heumen et al., 2009).
These include:
• Porcelain-fused-to-gold bridges have a favourable
• During treatment and once the required space has long-term survival rate of 68.3% after 20 years. Vi-
been achieved, a space maintainer such as an open tal teeth had about three times higher survival rates
coil spring or artificial denture tooth is attached to than endodontically treated teeth.
the orthodontic archwire. (Savarrio and McIntyre,
• The main reason for these failures was caries (30%)
2005).
(De Backer et al., 2008).
• Thermoplastic retainers or Hawley-type retainers
• Osseointegrated dental implants: If a dental implant
incorporating prosthetic teeth and wire stops should
is placed in the lateral incisor region, it should be
be used (Richardson and Russell, 2001).
placed in the correct restoratively determining 3D
• Removable partial dentures or bridges: They may be position (Yang et al., 2015).
the final long-term restoration if the patient chooses
Criteria for implant placement
not to have a dental implant in the long-term (Rada
et al., 2015). These include:
• Conventional porcelain fused to metal bridges: It • Mesial distal distance: At least 1.5 mm away from
is not recommended in young patients due to the the roots of adjacent teeth. Therefore, a minimum
large amount of tooth reduction required in teeth space of 6 mm mesiodistally is required for implants
with large pulps, so it is only placed after complete of 3.0 mm, as 1.5 mm space should be present on
growth. In young patients, the anterior spaces may either side of the dental implant (Kokich, 2004).
be closed and redistributed posteriorly for implant
• Vertical position: 2 and 3 mm (depending upon the
placement later; in the meanwhile, the posterior
design of the implant) apical to the anticipated gin-
space might be restored with interim bridges or
gival margin of the implant restoration.
bonded retainers (Kinzer and Kokich Jr, 2005).
• Labio-lingual position: At least 1.5 - 2 mm palatal
• Bonded orthodontic retainers, fixed resin bonded,
to the facial curvature of the arch, or point of emer-
or laboratory composite with fibre-reinforced bridg-
gence at the level of mucosal margin. A space of
es are recommended for longer interim periods to
1.5mm between the facial surface of the implant and
reduce root approximation.
the buccal cortex
• TADs supported prosthesis (Ciarlantini, 2019)
• Before debonding the fixed appliance, an appropri-
Types of final restorations ate measure of the inter-coronal/inter-radicular dis-
tances is essential.
1. Removable partial dentures: It is the restoration of choice
if the patient is unwilling to undergo lengthy and costly treat- Success of dental implants
ment.
A systematic review found success of dental implants after 5
2. Bridges years is 95.2%, and after 10yrs is 80%, though complications
occur in 24% of patients; mainly due to biological and techni-
• It includes adhesive or resin-bonded bridges (RBB),
cal factors (Pjetursson et al., 2012b). Clinical presentation of
fibre-reinforced composite bridges (FRCB) and por-
failed implants are:
220 HYPODONTIA
• Infraposition of single implant restorations Exam night review
• Peri-implant mucosal recession Hypodontia is the developmental absence of one or more
teeth, excluding third molars (Goodman et al., 1994). Also,
• Black triangles
known selective tooth agenesis (STHAG)
• Marginal bone loss around adjacent teeth and bone
Classification
loss buccally to the implants.
• Hypodontia
• Alteration of the contact point.
Agenesis of 1-6 teeth excluding third molars.
Treatment options for absent premolars
• Oligodontia
Treatment options depend on the amount of crowding:
Agenesis of more than six teeth, excluding the third molars.
• If the arch is spaced or aligned, preserve the de-
ciduous teeth, mainly deciduous second molars. If • Anodontia
the second deciduous molar survives until 20 years,
Complete absence of teeth.
they appear to have a good prognosis for long term
survival (Bjerklin and Bennett, 2000). If lower E is The candidate genes for non-syndromic hypodontia (Vas-
maintained, its mesiodistal width should be reduced tardis et al., 1996, Lammi et al., 2004, Cobourne, 2007b)
for optimum occlusion (premolarise). MSX1 and MSX2: MSX1 represents a candidate gene for
• In case of crowding, deciduous teeth should be ex- both syndromic and non-syndromic hypodontia.
tracted when appropriate. Extraction of upper E’s in • EDA.
Class II malocclusion and lower E’s in class 3 mal-
occlusion helps correct the overjet. For maximum • PAX9.
spontaneous space closure, consider extraction of • AXIN2
E’s at 9 years (Lindqvist, 1980). Consider controlled
sectioning of lower E’s to allow bodily space closure Incidence
(Hemi-sectioning). It has better success in patients Type of dentition: The incidence of hypodontia in decidu-
less than 9 yrs of age. (Valencia et al., 2004) ous teeth is 0.1-0.9 %. In permanent dentition 4-6% exclud-
Evidence summary ing third molars (Grahnén, 1956a).
• As per the systematic review and meta-analysis, Ethnicity variation: highest in Africa 13.4%, followed by
the prevalence of hypodontia is 6.4%, and it varies Europe 7%. Asian and Australians have the same prevalence
on different continents of the world. (Khalaf et al., of 6.3%. Gender variation: The incidence is 4.6% in males
2014) and 6.4% in females (Polder et al., 2004). Hypodontia is
more frequently reported in females.
• High chances of agenesis of lateral incisor in the
presence of peg laterals on contralateral side (Hua et Sequence of hypodontia: The common missing tooth types
al., 2013) in Caucasians are: lower second premolars > upper lateral
incisors > upper second premolars > lower central incisors
• Space closure is a better option if aesthetics allows (Larmour et al., 2005).
(Qadri et al., 2016, McNeill and Joondeph, 1973)
Third molars: These are the most commonly absent teeth
• Frequent debonding of resin-bonded bridges for with an incidence of 25-35% (Peck et al., 1996).
the replacement of missing teeth has been reported
(Thoma et al., 2017) Premolars: Premolars can form as late as 9 years of age.
Lower 5’s are the most commonly absent (2.6%), followed
• Failure of implant prosthesis can be reduced by con- by upper 5’s then 4’s (Wisth et al., 1974). Peck has reported
trolling biological and technical factors (Pjetursson a 3% incidence of missing second premolars (Peck et al.,
et al., 2012a). 1996).
Maxillary lateral incisors: Absent maxillary lateral incisors
constitute 2% of the population (Peck et al., 1996).
Lower incisors: Caucasians is 0.2% (J Neal and E Bowden,
1988).
Aetiology and theories of hypodontia
HYPODONTIA 221
• Evolutional theory: Decrease ins jaw size and tooth • Generalised spacing and rotation of teeth adjacent
number to the missing teeth
• Anatomical theory: Dental lamina in certain areas Complications/difficulties with treatment (Grahnén,
susceptible to environmental factors 1956b)
• Environmental theory: Chemotherapy, infections, • Anchorage difficulties
drugs, toxins, trauma, nutrition
• Atrophy and loss of bone
• Genetic factors: Polygenic multifactorial
• Root parallelism for implants
Features of malocclusion
• Aesthetics
Skeletal features (depending on the severity of malocclusion)
• Risk of relapse, e.g. spaces reopening
• Retrognathic and hypoplastic maxilla (Wisth et al.,
• Cost of treatment
1974, Hobkirk et al., 1995).
• Treatment time may be increased
• Small MMPA and reduced vertical dimensions.
(Taju et al., 2018). • Treatment outcome may be compromised
• Low mandibular plane angle is associated with re- • Common issues faced in treating these patients in-
duced lower anterior facial height and protrusive clude: space management, uprighting and aligning
lips (Chung et al., 2000). teeth, management of the deep overbite, and reten-
tion (Carter et al., 2003).
Alveolar features
Treatment factors (Hobkirk et al., 1995)
• Lack of alveolar bone
• Age.
• There is often a fairly flat palatal vault, resulting in
reduced anchorage capacity of upper removable ap- • Medical history.
pliances, Nance palatal arch, or implant placement. • Patient’s opinion and co-operation.
Occlusal features (Fekonja, 2005b) • Facial profile.
• Upright incisors. • Smile line.
• Over-erupted incisors. • Gingival line.
• Increased overbite • Malocclusion and extent of hypodontia.
Dental features • Intra- and inter-arch relationships
• Delayed and asymmetric eruption of permanent • Dental features size, shape, the colour of the adja-
teeth. cent teeth.
• Prolonged retention of primary teeth (Kurol and • Clinical situation of retained teeth.
Thilander, 1984).
Sequence of treatment (Spear et al., 1997)
• Infra-occlusion of primary teeth (Kurol and Thilan-
der, 1984). • Create a diagnostic set-up and Kesling set-up.
• Ectopic eruption or impaction of the adjacent teeth, • Determine the sequence of orthodontic treatment.
particularly maxillary canines. • Building-up malformed teeth and answering the
• Microdontia (Graber, 1978) following questions:
• Conical crown. (Brook, 1984) • Where should the maxillary lateral incisor (U2) be
positioned mesiodistally
• Transposition (Peck et al., 1996)
• Where should U2 be positioned buccolingual:
• Enamel hypoplasia.
• Where should U2 be positioned inciso-gingivally?
• Molar taurodontism
• Evaluate gingival aesthetic.
• Short roots
• Determine space required by golden proportion,
• Enamel hypoplasia universal mesiodistal width, contra-lateral tooth size
222 HYPODONTIA
or Bolton analysis (Bolton, 1958). References
• Provision of space to facilitate restorative treatment. AKRAM, A., JERREAT, A., WOODFORD, J., SANDY, J. & IRE-
LAND, A. 2011. Development of a condition‐specific measure to
• Take progress radiographs, and measure the space assess quality of life in patients with hypodontia. Orthodontics &
with the implant T ruler. craniofacial research, 14, 160-167.
• Occlusal adjustment. AKRAM, A. J., IRELAND, A., POSTLETHWAITE, K., SANDY,
J. & JERREAT, A. S. 2013. Assessment of a condition‐specific
• Interact with the restorative dentist during finish- quality‐of‐life measure for patients with developmentally absent
ing. teeth: validity and reliability testing. Orthodontics & craniofacial
Interim prosthesis for a space with a missing tooth research, 16, 193-201.
AL-ANI, A. H., ANTOUN, J. S., THOMSON, W. M., MERRIMAN,
• During treatment and once the required space has
T. R. & FARELLA, M. 2017a. Hypodontia: An Update on Its Etiol-
been achieved, a space maintainer such as an open ogy, Classification, and Clinical Management. BioMed research
coil spring or artificial denture tooth is attached to international, 2017, 9378325-9378325.
the orthodontic archwire. (Savarrio and McIntyre,
2005). AL-ANI, A. H., ANTOUN, J. S., THOMSON, W. M., MERRI-
MAN, T. R. & FARELLA, M. 2017b. Hypodontia: An Update on Its
• Thermoplastic retainers or Hawley-type retainers Etiology, Classification, and Clinical Management. Biomed Res Int,
incorporating prosthetic teeth and wire stops might 2017, 9378325.
be used (Richardson and Russell, 2001). AMM, E. W., ANTOSZEWSKA-SMITH, J. & BOLEY, J. 2019. Ca-
• Removable partial dentures or bridges: They may be nine substitution of congenitally missing maxillary lateral incisors
in Class I and Class III malocclusions by using skeletal anchorage.
the final long-term restoration if the patient doesn’t
Am J Orthod Dentofacial Orthop, 156, 512-521.e6.
want dental implants in the long term (Rada et al.,
2009). ANDREASEN, J. O., PAULSEN, H. U., YU, Z., AHLQUIST, R.,
BAYER, T. & SCHWARTZ, O. 1990a. A long-term study of 370 au-
• Bonded orthodontic retainers, fixed resin bonded or totransplanted premolars. Part I. Surgical procedures and standard-
laboratory composite with fibre-reinforced bridges. ized techniques for monitoring healing. Eur J Orthod, 12, 3-13.
Types of final restorations ANDREASEN, J. O., PAULSEN, H. U., YU, Z. & BAYER, T. 1990b.
A long-term study of 370 autotransplanted premolars. Part IV.
• Removable partial dentures Root development subsequent to transplantation. Eur J Orthod, 12,
• Bridges (Fixed partial dentures): It includes adhe- 38-50.
sive or resin-bonded bridges (RBB), fibre-reinforced ASHER, C. & LEWIS, D. H. 1986. The integration of orthodontic
composite bridges (FRCB) and porcelain fused to and restorative procedures in cases with missing maxillary incisors.
metal bridges (PFB). Br Dent J, 160, 241-5.
• Osseointegrated dental implants: ASLAN, B. I., UÇÜNCÜ, N. & DOĞAN, A. 2010. Long-term
follow-up of a patient with multiple congenitally missing teeth
Criteria for implant placement treated with autotransplantation and orthodontics. Angle Orthod,
80, 396-404.
• Mesio-distal position: at least 1.5 mm away from the
roots of adjacent teeth. BJERKLIN, K. & BENNETT, J. 2000. The long-term survival of
lower second primary molars in subjects with agenesis of the pre-
• Vertical position: 2 and 3 mm (depending upon the molars. Eur J Orthod, 22, 245-55.
design of the implant) apical to the anticipated gin-
gival margin of the implant restoration. BOLTON, W. A. 1958. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. The Angle Orthodon-
• Labio-lingual position: At least 1.5 - 2 mm palatal tist, 28, 113-130.
to the facial curvature of the arch or point of emer- BOZKAYA, E., CANIGUR BAVBEK, N. & ULASAN, B. 2018. New
gence at the level of mucosal margin. 1.5mm palatal perspective for evaluation of tooth widths in patients with missing
to the buccal cortex or peg-shaped maxillary lateral incisors: Quadrant analysis. Am J
BRIN, I., BECKER, A. & SHALHAV, M. 1986. Position of the max-
illary permanent canine in relation to anomalous or missing lateral
incisors: a population study. Eur J Orthod, 8, 12-6.
BROOK, A. H. 1984. A unifying aetiological explanation for anom-
alies of human tooth number and size. Arch Oral Biol, 29, 373-8.
HYPODONTIA 223
BROOK, A. H. 2009. Multilevel complex interactions between GRAHNÉN, H. 1956b. Hypodontia in the permanent dentition: a
genetic, epigenetic and environmental factors in the aetiology of clinical and genetic investigation. Odontol Revy, 7, 1-100.
anomalies of dental development. Arch Oral Biol, 54 Suppl 1, S3-
HALL, R. K. 1983. Congenitally missing teeth--a diagnostic feature
17.
in many syndromes of the head and neck. J Int Assoc Dent Child,
BURZYNSKI, N. J. & ESCOBAR, V. H. 1983. Classification and 14, 69-75.
genetics of numeric anomalies of dentition. Birth Defects Orig
HOBKIRK, J. A., GILL, D. S., JONES, S. P., HEMMINGS, K. W.,
Artic Ser, 19, 95-106.
BASSI, G. S., O’DONNELL, A. L. & GOODMAN, J. R. 2010. Hy-
CAMERON, J. & SAMPSON, W. J. 1996. Hypodontia of the per- podontia: a team approach to management, John Wiley & Sons.
manent dentition. Case reports. Aust Dent J, 41, 1-5.
HOBKIRK, J. A., GOODMAN, J. R. & JONES, S. P. 1994. Present-
CARTER, N. E., GILLGRASS, T. J., HOBSON, R. S., JEPSON, N., ing complaints and findings in a group of patients attending a
EECHAN, J. G., NOHL, F. S. & NUNN, J. H. 2003. The interdisci- hypodontia clinic. Br Dent J, 177, 337-9.
plinary management of hypodontia: orthodontics. Br Dent J, 194,
HOBKIRK, J. A., KING, P. A., GOODMAN, J. R. & JONES, S. P.
361-6.
1995. Hypodontia: 2. The management of severe hypodontia. Dent
CHUNG, L.-K., HOBSON, R., NUNN, J., GORDON, P. & CART- Update, 22, 8-11.
ER, N. 2000. An analysis of the skeletal relationships in a group of
HUA, F., HE, H., NGAN, P. & BOUZID, W. 2013. Prevalence of
young people with hypodontia. British Journal of Orthodontics, 27,
peg-shaped maxillary permanent lateral incisors: A meta-analysis.
315-318.
COBOURNE, M. 2007a. Familial human hypodontia–is it all in the
HUSSEY, D. L. & LINDEN, G. J. 1996. The clinical performance of
genes? British dental journal, 203, 203.
cantilevered resin-bonded bridgework. J Dent, 24, 251-6.
COBOURNE, M. T. 2007b. Familial human hypodontia--is it all in
J NEAL, J. & E BOWDEN, D. 1988. The diagnostic value of pan-
the genes? British dental journal, 203, 203-208.
oramic radiographs in children aged nine to ten years.
JUMLONGRAS, D., BEI, M., STIMSON, J. M., WANG, W. F.,
DEPALMA, S. R., SEIDMAN, C. E., FELBOR, U., MAAS, R., SEID-
COBOURNE, M. T., FLEMING, P. S., DIBIASE, A. T. & AHMAD, MAN, J. G. & OLSEN, B. R. 2001. A nonsense mutation in MSX1
S. 2012. Clinical cases in orthodontics, John Wiley & Sons. causes Witkop syndrome. Am J Hum Genet, 69, 67-74.
CREUGERS, N. H., KAYSER, A. F. & VAN’T HOF, M. A. 1992. A KHALAF, K., MISKELLY, J., VOGE, E. & MACFARLANE, T. V.
seven-and-a-half-year survival study of resin-bonded bridges. J 2014. Prevalence of hypodontia and associated factors: a systematic
Dent Res, 71, 1822-5. review and meta-analysis. J Orthod, 41, 299-316.
DE BACKER, H., VAN MAELE, G., DE MOOR, N. & VAN DEN KINZER, G. A. & KOKICH JR, V. O. 2005. Managing Congenitally
BERGHE, L. 2008. Long-term results of short-span versus long- Missing Lateral Incisors. Part II: Tooth-Supported Restorations.
span fixed dental prostheses: an up to 20-year retrospective study. Journal of Esthetic and Restorative Dentistry, 17, 76-84.
International Journal of Prosthodontics, 21.
KIRZIOGLU, Z., KOSELER SENTUT, T., OZAY ERTURK, M. S.
ENDO, T., OZOE, R., KUBOTA, M., AKIYAMA, M. & SHI- & KARAYILMAZ, H. 2005. Clinical features of hypodontia and
MOOKA, S. 2006. A survey of hypodontia in Japanese orthodontic associated dental anomalies: a retrospective study. Oral Dis, 11,
patients. Am J Orthod Dentofacial Orthop, 129, 29-35. 399-404.
FEKONJA, A. 2005a. Hypodontia in orthodontically treated chil- KJÆR, I., KOCSIS, G., NODAL, M. & CHRISTENSEN, L. R. 1994.
dren. European Journal of Orthodontics, 27, 457-460. Aetiological aspects of mandibular tooth agenesis—focusing on the
role of nerve, oral mucosa, and supporting tissues. The European
FEKONJA, A. 2005b. Hypodontia in orthodontically treated chil-
Journal of Orthodontics, 16, 371-375.
dren. Eur J Orthod, 27, 457-60.
KOKICH, V. G. 2004. Maxillary lateral incisor implants: planning
GILBERT-BARNESS, E. 2010. Teratogenic causes of malforma-
with the aid of orthodontics. Journal of Oral and Maxillofacial
tions. Ann Clin Lab Sci, 40, 99-114.
Surgery, 62, 48-56.
GILL, D. S. & BARKER, C. S. 2015. The multidisciplinary manage-
KOKICH, V. O., JR. & KINZER, G. A. 2005. Managing congenitally
ment of hypodontia: a team approach. Br Dent J, 218, 143-9.
missing lateral incisors. Part I: Canine substitution. J Esthet Restor
GOODMAN, J., JONES, S., HOBKIRK, J. & KING, P. 1994. Dent, 17, 5-10.
Hypodonta 1: Clinical features and the management of mild to
KOKICH, V. O., JR., KINZER, G. A. & JANAKIEVSKI, J. 2011.
moderate hypodontia. Dental Update, 21, 381-384.
Congenitally missing maxillary lateral incisors: restorative replace-
GRABER, L. W. 1978. Congenital absence of teeth: a review with ment. Counterpoint. Am J Orthod Dentofacial Orthop, 139, 435,
emphasis on inheritance patterns. J Am Dent Assoc, 96, 266-75. 437, 439 passim.
GRAHNÉN, H. 1956a. Hypodontia in the permanent dentition. KUROL, J. & THILANDER, B. 1984. Infraocclusion of primary
Odontol Revy, 7, 1-100. molars and the effect on occlusal development, a longitudinal
study. Eur J Orthod, 6, 277-93.
224 HYPODONTIA
LAMMI, L., ARTE, S., SOMER, M., JARVINEN, H., LAHERMO, implants research, 23, 22-38.
P., THESLEFF, I., PIRINEN, S. & NIEMINEN, P. 2004. Mutations
POLDER, B. J., VAN’T HOF, M. A., VAN DER LINDEN, F. P. &
in AXIN2 cause familial tooth agenesis and predispose to colorec-
KUIJPERS-JAGTMAN, A. M. 2004. A meta-analysis of the preva-
tal cancer. Am J Hum Genet, 74, 1043-50.
lence of dental agenesis of permanent teeth. Community Dent Oral
LARMOUR, C. J., MOSSEY, P. A., THIND, B. S., FORGIE, A. H. Epidemiol, 32, 217-26.
& STIRRUPS, D. R. 2005. Hypodontia--a retrospective review of
PRÖBSFER, B. & HENRICH, G. M. 1997. 11-year follow-up study
prevalence and etiology. Part I. Quintessence Int, 36, 263-70.
of resin-bonded fixed partial dentures. International Journal of
LINDQVIST, B. 1980. Extraction of the deciduous second molar in Prosthodontics, 10.
hypodontia. Eur J Orthod, 2, 173-81.
QADRI, S., PARKIN, N. A. & BENSON, P. E. 2016. Space closing
MCDOWALL, R. J., YAR, R. & WARING, D. T. 2012. 2 ‘2’ 1: Orth- versus space opening for bilateral missing upper laterals - aesthetic
odontic repositioning of lateral incisors into central incisors. Br judgments of laypeople: a web-based survey. J Orthod, 43, 137-46.
Dent J, 212, 417-23.
RADA, R., BAKHSH, H. H. & EVANS, C. 2015. Orthodontic care
MCNEILL, R. W. & JOONDEPH, D. R. 1973. Congenitally absent for the behavior-challenged special needs patient. Spec Care Den-
maxillary lateral incisors: treatment planning considerations. Angle tist, 35, 138-42.
Orthod, 43, 24-9.
RAKHSHAN, V. & RAKHSHAN, H. 2016. Meta-analysis and
MIRABELLA, A. D., KOKICH, V. G. & ROSA, M. 2012. Analysis systematic review of the number of non-syndromic congenitally
of crown widths in subjects with congenitally missing maxillary missing permanent teeth per affected individual and its influencing
lateral incisors. Eur J Orthod, 34, 783-7. factors. Eur J Orthod, 38, 170-7.
NÄSMAN, M., FORSBERG, C.-M. & DAHLLÖF, G. 1997. Long- RICHARDSON, G. & RUSSELL, K. A. 2001. Congenitally missing
term dental development in children after treatment for malignant maxillary lateral incisors and orthodontic treatment considerations
disease. European journal of orthodontics, 19, 151-159. for the single-tooth implant. J Can Dent Assoc, 67, 25-8.
NIEMINEN, P., ARTE, S., PIRINEN, S., PELTONEN, L. & ROBERTSSON, S. & MOHLIN, B. 2000. The congenitally missing
THESLEFF, I. 1995. Gene defect in hypodontia: exclusion of MSX1 upper lateral incisor. A retrospective study of orthodontic space
and MSX2 as candidate genes. Hum Genet, 96, 305-8. closure versus restorative treatment. Eur J Orthod, 22, 697-710.
NORDQUIST, G. G. & MCNEILL, R. W. 1975. Orthodontic vs. ROLLING, S. 1980. Hypodontia of permanent teeth in Danish
restorative treatment of the congenitally absent lateral incisor--long schoolchildren. Scand J Dent Res, 88, 365-9.
term periodontal and occlusal evaluation. J Periodontol, 46, 139-
ROSA, M., LUCCHI, P., FERRARI, S., ZACHRISSON, B. U. &
43.
CAPRIOGLIO, A. 2016. Congenitally missing maxillary lateral
PADUANO, S., CIOFFI, I., RONGO, R., CUPO, A., BUCCI, R. & incisors: Long-term periodontal and functional evaluation after
VALLETTA, R. 2014. Orthodontic management of congenitally orthodontic space closure with first premolar intrusion and canine
missing maxillary lateral incisors: a case report. Case reports in extrusion. Am J Orthod Dentofacial Orthop, 149, 339-48.
dentistry, 2014.
SARNAS, K. V. & RUNE, B. 1983. The facial profile in advanced
PARKIN, N., BAZARGANI, F., BENSON, P. E. & ATWAL, A. 2017. hypodontia: a mixed longitudinal study of 141 children. Eur J
Interventions for promoting the eruption of palatally displaced Orthod, 5, 133-43.
permanent canine teeth, without the need for surgical exposure, in
SAVARRIO, L. & MCINTYRE, G. T. 2005. To open or to close
children aged 9 to 14 years. The Cochrane Database of Systematic
space--that is the missing lateral incisor question. Dent Update, 32,
Reviews, 2017, CD012851.
16-8, 20-2, 24-5.
PARKIN, N., ELCOCK, C., SMITH, R., GRIFFIN, R. & BROOK,
SCHNEIDER, U., MOSER, L., FORNASETTI, M., PIATTELLA, M.
A. 2009. The aetiology of hypodontia: the prevalence, severity and
& SICILIANI, G. 2016. Esthetic evaluation of implants vs canine
location of hypodontia within families. Archives of Oral Biology,
substitution in patients with congenitally missing maxillary lateral
54, S52-S56.
incisors: Are there any new insights? Am J Orthod Dentofacial
PECK, S., PECK, L. & KATAJA, M. 1996. Site-specificity of tooth Orthop, 150, 416-24.
agenesis in subjects with maxillary canine malpositions. Angle
SHAW, W. C., ADDY, M. & RAY, C. 1980. Dental and social ef-
Orthod, 66, 473-6.
fects of malocclusion and effectivenessof orthodontic treatment: a
PJETURSSON, B. E., THOMA, D., JUNG, R., ZWAHLEN, M. review. Community Dent Oral Epidemiol, 8, 36-45.
& ZEMBIC, A. 2012a. A systematic review of the survival and
SILVEIRA, G. S., DE ALMEIDA, N. V., PEREIRA, D. M., MAT-
complication rates of implant-supported fixed dental prostheses
TOS, C. T. & MUCHA, J. N. 2016. Prosthetic replacement vs space
(FDPs) after a mean observation period of at least 5 years. Clin
closure for maxillary lateral incisor agenesis: A systematic review.
Oral Implants Res, 23 Suppl 6, 22-38.
PJETURSSON, B. E., THOMA, D., JUNG, R., ZWAHLEN, M. &
SISMAN, Y., UYSAL, T. & GELGOR, I. E. 2007. Hypodontia.
ZEMBIC, A. 2012b. A systematic review of the survival and com-
Does the prevalence and distribution pattern differ in orthodontic
plication rates of implant‐supported fixed dental prostheses (FDP
patients? Eur J Dent, 1, 167-73.
s) after a mean observation period of at least 5 years. Clinical oral
HYPODONTIA 225
SPEAR, F. M., MATHEWS, D. M. & KOKICH, V. G. 1997. Inter- health-related quality of life and severe hypodontia. J Oral Rehabil,
disciplinary management of single-tooth implants. Semin Orthod, 33, 869-73.
3, 45-72.
YANG, L., LI, F., CAO, M., CHEN, H., WANG, X., CHEN, X.,
STEVENSON, B., PATEL, D., RICKETTS, D. & CORD, A. 2013. YANG, L., GAO, W., PETRONE, J. F. & DING, Y. 2015. Quantita-
The orthodontic-restorative interface in patients with hypodontia: tive evaluation of maxillary interradicular bone with cone-beam
the patient’s journey. Dent Update, 40, 354-6, 358-60. computed tomography for bicortical placement of orthodontic
mini-implants. American Journal of Orthodontics and Dentofacial
SVINHUFVUD, E., MYLLÄRNIEMI, S. & NORIO, R. 1988.
Dominant inheritance of tooth malpositions and their association
to hypodontia. Clinical Genetics, 34, 373-381. YANOSKY, M. R. & HOLMES, J. D. 2008. Mini-implant temporary
anchorage devices: orthodontic applications. Compend Contin
SYMONS, A. L., STRITZEL, F. & STAMATION, J. 1993. Anomalies
Educ Dent, 29, 12-20; quiz 21, 30.
associated with hypodontia of the permanent lateral incisor and
second premolar. J Clin Pediatr Dent, 17, 109-11. ZACHRISSON, B. U. 2007. Improving the esthetic outcome of
canine substitution for missing maxillary lateral incisors. World J
TAJU, W., SHERRIFF, M., BISTER, D. & SHAH, S. 2018. Associa-
Orthod, 8, 72-9.
tion between severity of hypodontia and cephalometric skeletal
patterns: a retrospective study. Eur J Orthod, 40, 200-205. ZACHRISSON, B. U., ROSA, M. & TORESKOG, S. 2011. Congeni-
tally missing maxillary lateral incisors: canine substitution. Ameri-
THESLEFF, I. 1996. Two genes for missing teeth. Nat Genet, 13,
can journal of orthodontics and dentofacial orthopedics, 139, 434.
379-80.
ZACHRISSON, B. U., STENVIK, A. & HAANAES, H. R. 2004.
THILANDER, B. 2000. Orthodontic relapse versus natural devel-
Management of missing maxillary anterior teeth with emphasis on
opment. Am J Orthod Dentofacial Orthop, 117, 562-3.
autotransplantation. Am J Orthod Dentofacial Orthop, 126, 284-8.
THILANDER, B., ODMAN, J., GRÖNDAHL, K. & FRIBERG, B.
ZHU, J. F., MARCUSHAMER, M., KING, D. L. & HENRY, R. J.
1994. Osseointegrated implants in adolescents. An alternative in
1996. Supernumerary and congenitally absent teeth: a literature
replacing missing teeth?
review. J Clin Pediatr Dent, 20, 87-95.
THOMA, D. S., SAILER, I., IOANNIDIS, A., ZWAHLEN, M.,
ZILBERMAN, Y., COHEN, B. & BECKER, A. 1990. Familial trends
MAKAROV, N. & PJETURSSON, B. E. 2017. A systematic review
in palatal canines, anomalous lateral incisors, and related phenom-
of the survival and complication rates of resin-bonded fixed dental
ena. Eur J Orthod, 12, 135-9.
prostheses after a mean observation period of at least 5 years. Clin
Oral Implants Res, 28, 1421-1432.
VALENCIA, R., SAADIA, M. & GRINBERG, G. 2004. Controlled
slicing in the management of congenitally missing second premo-
lars. Am J Orthod Dentofacial Orthop, 125, 537-43.
VAN HEUMEN, C. C., VAN DIJKEN, J. W., TANNER, J., PI-
KAAR, R., LASSILA, L. V., CREUGERS, N. H., VALLITTU, P. K.
& KREULEN, C. M. 2009. Five-year survival of 3-unit fiber-rein-
forced composite fixed partial dentures in the anterior area. dental
materials, 25, 820-827.
VASTARDIS, H. 2000. The genetics of human tooth agenesis: new
discoveries for understanding dental anomalies. American Journal
of Orthodontics and Dentofacial Orthopedics, 117, 650-656.
VASTARDIS, H., KARIMBUX, N., GUTHUA, S. W., SEIDMAN,
J. G. & SEIDMAN, C. E. 1996. A human MSX1 homeodomain
missense mutation causes selective tooth agenesis. Nat Genet, 13,
417-21.
VISINONI, A. F., LISBOA-COSTA, T., PAGNAN, N. A. & CHAU-
TARD-FREIRE-MAIA, E. A. 2009. Ectodermal dysplasias: clinical
and molecular review. Am J Med Genet A, 149a, 1980-2002.
WILMES, B., WILLMANN, J., STOCKER, B. & DRESCHER, D.
2015. The Benefit System and its scope in contemporary orthodon-
tic protocols. APOS Trends in Orthodontics, 5, 174-180.
WISTH, P. J., THUNOLD, K. & BOE, O. E. 1974. The craniofacial
morphology of individuals with hypodontia. Acta Odontol Scand,
32, 281-290.
WONG, A. T., MCMILLAN, A. S. & MCGRATH, C. 2006. Oral
226 HYPODONTIA
Supernumerary Teeth
22
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam, Lubna Almuzian , Abbas Naseem
In this Chapter
1. Incidence of supernumerary teeth
2. Aetiology of supernumerary teeth
3. Genetic influences
4. Clinical features of supernumerary
teeth
5. Classification of supernumerary teeth
6. Examination of supernumerary tooth
7. Management of supernumerary tooth
8. Detailed management of each type of supernu
merary
9. The recommendations of the Royal College of
Surgeon of England
10. Evidence summary
228 SUPERNUMERARY TEETH

Sdevelops
upernumerary is ‘tooth’ or a ‘tooth-like’ structure which
• Dichotomy: Dichotomy of tooth bud and fragmen-
tation of dental lamina e.g. during cleft formation
in addition to the normal number of teeth, also (Amarlal and Muthu, 2013).
known as hyperdontia
• Atavistic theory: Supernumerary teeth can also be
Incidence of supernumerary teeth the result of the reversion or atavism phenomenon.
In summary: Atavism is the reappearance of an ancestral condi-
tion or type or a long-distance heredity or phyloge-
• The male to female ratio was found to be 2:1 up to netic reversion. Phylogenetic evolution has resulted
3:1 in the permanent dentition (Shah et al., 2008, in a reduction in the number and size of teeth. Su-
Fleming et al., 2010). pernumerary teeth may be an atavistic appearance
• There is no sexual dimorphism in primary dentition of extinct primate teeth in the premolar and incisor
(Shah et al., 2008, Fleming et al., 2010). region. (Mallineni, 2014, Primosch, 1981).
• Supernumerary teeth are 5-10 times more common • Local, independent or conditioned hyperactivity of
in the maxilla than in the mandible (Alvira-Gonza- dental lamina: Supernumerary can also result from
lez and Gay-Escoda, Ata-Ali et al., 2014, Scheiner disturbances during the initiation and proliferation
and Sampson, 1997). stages of dental development and, like tooth agen-
esis, can occur as part of a larger disease process,
• The incidence of supernumerary teeth in primary syndrome or as an idiopathic finding. (Proffit et al.,
dentition is 0.06% to 0.8% (Cobourne et al., 2012, 2018).
Brook, 1974).
Genetic influences in the development of supernumerary
• Supernumerary in the primary dentition is often fol- teeth
lowed by a supernumerary in the permanent denti-
tion (Littlewood and Mitchell, 2019, Lu et al., 2017). Genetic influence can be appreciated by the fact that:
• The incidence of supernumerary teeth in the perma- • 20.5% of patient also had first-degree relatives with
nent dentition in the Caucasian population is 1-2% a supernumerary teeth (McBeain and Miloro, 2018),
(Garvey et al., 1999, Shah et al., 2008) of which 80 • Association with specific medical and dental disor-
% are present in the anterior maxilla, mostly in the ders (Rajab and Hamdan, 2002),
central incisor region 51.2% (Di Biase, 1969, Mc-
Beain and Miloro, 2018). • Ethnic variations,
• Supernumerary teeth in the premolar and molar re- • Sexual dimorphism (Rajab and Hamdan, 2002)
gions occur at the incidence of 10% of all supernu- Following patterns of inheritance may be observed: (Fleming
merary cases (Hyun et al., 2008). et al., 2010)
• Supernumerary teeth can be presented unilater- • Autosomal dominant with incomplete penetrance
ally or bilaterally and can occur individually or in
groups. A meta-analysis found bilateral occurrence • Sex linked trait
more common in non-syndromic multiple super- • Autosomal recessive trait with lesser penetrance in
numerary teeth (Alvira-Gonzalez and Gay-Escoda, females
2012) however, multiple supernumerary teeth could
Table 1: Syndromes associated with supernumerary teeth
be an indicator of an underlying medical disorder
(Subasioglu et al., 2015). Syndrome
• Supernumerary teeth can occur either as an isolated Cleft lip and palate
trait or as a manifestation of a clinical syndrome
Cleidocranial dyplasia (gene RUNX2)
(Shah et al., 2008) Table 1
Gardner syndrome (gene APC)
• In the CLP cases, the prevalence of supernumeraries
Ellis–van Creveld (gene EVC; EVC2)
is as high as 1.9 to 10%, due to the disruption of the
dental lamina during cleft formation. (Akcam et al., Incontinentia pigmenti (gene NEMO)
2010). Down’s syndrome and its association with Cleft lip and pal-
ate
Aetiology of supernumerary teeth
Ehlers-Danlos syndrome
Different theories have been suggested for the aetiology of su-
pernumerary teeth (Garvey et al., 1999). These are:
SUPERNUMERARY TEETH 229

Clinical features and effects of supernumerary teeth • Supplemental
These include: • Odontomes
• Asymptomatic: supernumerary teeth may remain Supplemental supernumerary teeth are further classified into
unerupted and asymptomatic in the permanent den- (Primosch, 1981):
tition, usually detected as a chance finding during
• Supplemental: This may also be termed incisiform
routine radiographic screening.
or eumorphic. In this form, shape and size is normal.
• Failure of eruption of adjacent permanent teeth:
• Rudimentary or dysmorphic: There is an abnormal
This is the most common cause of unerupted per-
shape and smaller size in this type. These include
manent central incisors (Seehra et al.) According to
conical, tuberculate, and molariform.
He et al., 23.1% of patients in the mixed dentition
with supernumerary teeth also have impacted inci- Kalra also classified supernumerary teeth according to mor-
sors (He et al., 2017). For every increase in one su- phology and number as an accessory (with abnormal mor-
pernumerary tooth, the risk of an impacted incisor phology) and supplemental (with morphology similar to nor-
increases by more than double. mal teeth) (Kalra et al., 2005)
•
Localised crowding/irregularity or displacement: 3. Position
This can be caused directly due to the eruption of
• Buccal
a supplemental tooth or indirectly by causing dis-
placements or rotations of adjacent erupted teeth. • Palatal
• Spacing between erupted teeth: 10% of midline • Transverse
diastemas are due to supernumeraries. Mesiodens 4. Numbers (Garvey et al., 1999)
produces a maxillary midline diastema between the
central incisors. • Single
• Resorption of the roots of teeth adjacent to a super- • Multiple.
numerary tooth, though it is very rare (Hogstrom 5. Orientation
and Andersson, 1987)
• Vertical
• Aesthetic impact if the supernumerary teeth erupt.
Supernumerary primary teeth may erupt into good • Horizontal
alignment due to the spaced dentition (Fleming et • Inverted
al., 2010).
Examination of supernumerary tooth
Classification of supernumerary teeth
It involves:
Supernumerary teeth have been classified in the literature
according to location and morphology, shape, position and 1. Visual examination of the sign of a supernumerary tooth,
number form. Less common classifications include chronol- which includes but is not limited to:
ogy and topography, clinical status, sagittal/vertical positions, • Erupted supernumerary
developmental stage, clinical complication and surgical ap-
proach (Amarlal and Muthu, 2013). Different parameters • Delayed tooth eruption and asymmetric eruption
used to classify supernumerary teeth are as follows (Mal- • Diastema
lineni, 2014) :
• Rotation or abnormal inclination of the adjacent
1. Location
• Colour change or mobility of the adjacent teeth
• Mesiodens
2. Clinical examination includes:
• Paramolar
• Mobility
• Distomolar
• Vitality
• Parapremolar
• Palpation
2. Morphology
3. Radiographic examination
• Conical
• Occlusal and/or periapical radiographs can be used
• Tuberculate to detect the position of an unerupted or supernu-

merary tooth (Garvey et al., 1999, Tsai, 2002, An- • Asymptomatic tooth not affecting occlusal relation-
thonappa et al., 2012) ships of erupted dentition.
• Parallax technique is used to determine the bucco- • Not associated with pathology.
lingual position of unerupted supernumerary teeth.
• No active orthodontic treatment is needed or if
Parallax techniques include vertical parallax using
orthodontic treatment is required and supernumer-
an OPG with periapical/ occlusal and horizontal
ary teeth do not interfere with tooth movement.
parallax with two periapical radiographs.
• Extraction would compromise the vitality of adja-
• If calcification is under 30%, the supernumerary
cent teeth.
tooth will not be seen on a radiograph. (Southall and
Gravely, 1989) Detailed management of each type of supernumerary
Management of supernumerary tooth Conical supernumerary
Treatment depends on several factors, such as the age of the Conical supernumeraries are the most common type of su-
patient, position of the supernumerary tooth, the potential pernumerary tooth in the permanent dentition and consti-
effect on adjacent teeth, and the type of the supernumerary tute 75% of all supernumerary teeth.
tooth. Treatment options (Chawla and Atack, 2012) are:
In terms of morphology, conical supernumeraries are small
1. Extraction of supernumerary teeth is recom-
peg-shaped teeth with normal, well-developed roots. They
mended in the following cases:
are occasionally located high and inverted into the palate or
• Delayed/failure of eruption of central incisors. If suf- positioned horizontally. Usually, the long axis of the tooth is
ficient space is available in the arch, removing super- normally inclined. May erupt or stay remain impacted.
numerary tooth overlying permanent incisor causes
There are three types of conical supernumeraries according
spontaneous eruption within 16 months in 54-78%
to the location of the conical supernumerary tooth:
of cases (Mitchell and Bennett, 1992, Witsenburg
and Boering, 1981). Permanent incisors were more • Mesiodens: Located in the midline of the anterior
likely to erupt without orthodontic treatment when maxilla, may cause median diastema. (Primosch,
the supernumerary teeth were extracted from the 1981). Prevalence of conical mesiodens ranges from
primary dentition than from mixed dentition (Jung 8 to 34%. (Tay et al., 1984, Bodin et al., 1981)
et al., 2016). Maxillary incisors which have been im- • Paramolar: Present in the maxillary molar region
pacted due to obstruction caused by supernumerary and can be buccal, lingual or interproximal to the
tooth have a better prognosis than the failure of the second and third molars.
eruption caused by other causes. (Betts and Camil-
leri, 1999). • Distomolar: Located distal to the third molar.
• Altered eruption or displacement of central incisors. The effect of conical supernumerary on permanent incisors
are:
• Associated pathology; follicular enlargement, cystic
formation or root resorption of adjacent teeth. • Rotation or displacement.
• Localised crowding. • Little effect on the eruption.
• Spacing produced between erupted teeth due to su- • Risk of cystic formation/resorption is very low (Ty-
pernumerary tooth removal must be performed be- rologou et al., 2005).
fore orthodontic alignment to avoid root resorption • Spacing: According to a study by Jung et al., super-
of adjacent teeth. numerary teeth were most frequently observed in
• Presence of supernumerary teeth could compromise the central incisor region, in the palatal position,
secondary alveolar bone grafting in cleft palate pa- and are inverted. Most commonly conical in shape,
tients, so their extraction is advised at least a month median diastema was the most common complica-
before alveolar bone grafting. tion. (Jung et al., 2016)
• Presence of supernumerary in a potential implant Treatment of conical supernumerary include extraction of
site may compromise implant placement. conical supernumeraries (>8 years).
2. Monitoring with a periodic radiographic review (radio- Tuberculate supernumerary
graph examination should be undertaken 6-9 months apart Tuberculate supernumeraries constitute 12% of all super-
following the ALARP rule) is recommended in the following numeraries. They usually presented as multicusped, barrel-
scenarios:

shaped tooth, with possible invaginations which lack full root the presence of supplemental teeth is made on the best size,
development. These mostly remain unerupted and often oc- colour, morphologic characteristics, and position related to
cur in pairs. Usually, any supernumerary that does not fall the other teeth. The tooth nearest to the planned final posi-
into the conical or supplemental supernumerary classification should be retained without pathology or differences in
tion is included in this category. (Littlewood and Mitchell, morphology. (Proffit et al., 2018)
2019)
Odontomes supernumerary
Tuberculate supernumeraries are mostly present on the pala-
Odontomes constitute 6% of supernumerary teeth and ac-
tal aspect of maxillary permanent central incisors, if the cen-
count for 65% of all odontogenic tumours in the Caucasian
tral incisor is unerupted, the tuberculate supernumerary is
population. Odontomes are more common in permanent
close / associated with the cingulum of the incisor tooth.
dentition and are rarely found in the primary dentition (Katz,
The effect of Tuberculate supernumeraries on permanent in- 1989). They are hamartomatous or developmental malfor-
cisors are: mations containing enamel, dentine and pulp. There are two
types of Odontomas:
• Rotation.
a. Complex Odontomes are large disorganised rounded
• Frequently associated with delayed eruption or ob-
masses of dentine, pulp and enamel. They are found in the
struction of permanent central incisors. (Foster and
posterior jaw, and 50% of complex odontomas interfere with
Taylor, 1969).
the eruption of adjacent teeth.
• Tuberculate are more likely to obstruct than conical
b. Compound Odontoma contain many small separate tooth-
(1:1 compared with 1:5). (Yaqoob et al., 2010).
like structures (discrete denticles), each having dentine, pulp
Treatment of tuberculate supernumerary includes extrac- and enamel. They are mostly found in the anterior jaw.
tion of tuberculate supernumeraries should be done to allow Compound odontomas are four times more common than
eruption of incisors. Spontaneous eruption of previously im- complex odontomas. But only 1/3rd of compound odonto-
pacted incisors occurs in only 50% of cases of the extraction mas prevent the eruption of adjacent teeth. 71.4% of odon-
of these teeth. tomas in the premaxillary region showed delayed eruption of
the adjacent incisors (Jung et al., 2016).
Supplemental supernumerary teeth

They constitute 7% of all supernumerary teeth and are the
most common supernumerary tooth found in the primary Evidence summary
dentition. They are a duplication of a tooth within a series.
In a literature review (Ata-Ali et al., 2014), it is reported that
Supplemental supernumerary teeth resemble crown mor- supernumerary teeth are:
phology of adjacent tooth, challenging to differentiate from
• More frequently found in males in the permeant
the normal tooth. Usually, they erupt into the oral cavity
dentition.
and cause crowding. Supplemental supernumerary teeth are
found at the end of a dental series, and they can be seen in • More common in anterior maxilla
the incisor, premolar and molar region; for example, an ad-
• More prevalent in the permanent dentition
ditional lateral incisor, second premolar, or fourth molar is a
supplemental tooth. • Treatment depends upon types, age and associated
complications, like ectopic and delayed eruption,
Treatment of supplemental supernumerary teeth include
dental impactions, crowding, spacing and follicular
extraction of most displaced or deformed tooth to relieve
cyst formation.
crowding. Root form must be assessed radiographically be-
fore extraction. 90.4% of supernumerary premolars included A meta-analysis on non-syndromic multiple supernumerary
in a study by Martínez-González had a supplementary mor- teeth found: (Alvira-Gonzalez and Gay-Escoda, 2012)
phology. (Martinez-Gonzalez et al., 2010). Supernumerary
• More often bilateral than unilateral.
premolars are usually diagnosed as a chance in radiographic
finding without an associated pathology. However, this study • More common in the mandible (The evidence is
states mechanical or obstructive pathology was associated multiple supernumeraries).
with 2.7% of the premolars and enlargement of the follicular
sac more significant than 3 millimetres was present in 26% of
the sample. In a study by Jung et al., displacement of incisors
was more frequently observed in association with the tuber-
culate or supplemental type of premaxillary supernumerary
teeth. (Jung et al., 2016) The decision to extract a tooth in

• Supernumerary tooth causing Spacing.
• Supernumerary that compromises secondary alveo-
Exam night review
lar bone grafting
Tooth/ Tooth-like’ structure develops in addition to the
• Potential implant site.
normal number of teeth.
Indications for monitoring
Incidence
• Asymptomatic →not affecting occlusal relationships.
• 5-10 times more common in the maxilla
• No pathology.
• Primary dentition → 0.06% to 0.8%
• No interference in Orthodontic tooth movement.
• Permanent dentition → 1-2%
• Extraction →compromises the vitality of adjacents.
• CLP → 1.9 to 10%
Aetiology
• Dichotomy: Dichotomy of tooth bud and fragmen-
tation of dental lamina.
• Atavistic theory:
• Local, independent or conditioned hyperactivity of
dental lamina.

Clinical features and effect of Supernumerary teeth on
permanent incisors
• Asymptomatic
• Failure of eruption of adjacent permanent teeth.
• Localised crowding/irregularity or displacement
• Spacing between erupted teethResorption of roots
• Aesthetic impact if supernumerary erupts.
Classification of supernumerary teeth
Location
• Mesiodens
• Paramolar
• Distomolar
• Parapremolar
Morphology
• Conical
• Tuberculate
• Supplemental
• Odontomes
Indications for extraction
• Supernumerary tooth overlying permanent incisor
• Associated pathology
• Localised crowding.

premaxillary supernumerary teeth on permanent incisors. Imaging
Sci Dent, 46, 251-258.
References
KALRA, N., CHAUDHARY, S. & SANGHI, S. 2005. Non-syn-
AKCAM, M. O., EVIRGEN, S., USLU, O. & MEMIKOĞLU, U. T.
drome multiple supplemental supernumerary teeth. J Indian Soc
2010. Dental anomalies in individuals with cleft lip and/or palate.
Pedod Prev Dent, 23, 46-8.
KATZ, R. W. 1989. An analysis of compound and complex odonto-
ALVIRA-GONZALEZ, J. & GAY-ESCODA, C. 2012. Non-syn-
mas. ASDC J Dent Child, 56, 445-9.
dromic multiple supernumerary teeth: meta-analysis. J Oral Pathol
Med, 41, 361-6. LITTLEWOOD, S. J. & MITCHELL, L. 2019. An introduction to
orthodontics, Oxford university press.
AMARLAL, D. & MUTHU, M. S. 2013. Supernumerary teeth:
review of literature and decision support system. Indian J Dent Res, LU, X., YU, F., LIU, J., CAI, W., ZHAO, Y., ZHAO, S. & LIU, S.
24, 117-22. 2017. The epidemiology of supernumerary teeth and the associated
molecular mechanism. Organogenesis, 13, 71-82.
ANTHONAPPA, R. P., KING, N. M., RABIE, A. B. & MALLINE-
NI, S. K. 2012. Reliability of panoramic radiographs for identifying MALLINENI, S. K. Supernumerary teeth: Review of the literature
supernumerary teeth in children. Int J Paediatr Dent, 22, 37-43. with recent updates. Conference Papers in Science, 2014. Hindawi.
ATA-ALI, F., ATA-ALI, J., PENARROCHA-OLTRA, D. & PENAR- MARTINEZ-GONZALEZ, J. M., BRINKMANN, J. C., CALVO-
ROCHA-DIAGO, M. 2014. Prevalence, etiology, diagnosis, treat- GUIRADO, J. L., ARIAS-IRIMIA, O. & BARONA-DORADO, C.
ment and complications of supernumerary teeth. J Clin Exp Dent, 2010. A clinical epidemiologic analysis of a sample of 73 supernu-
6, e414-8. merary premolars. J Am Dent Assoc, 141, 1435-41.
BETTS, A. & CAMILLERI, G. E. 1999. A review of 47 cases of MCBEAIN, M. & MILORO, M. 2018. Characteristics of Supernu-
unerupted maxillary incisors. Int J Paediatr Dent, 9, 285-92. merary Teeth in Nonsyndromic Population in an Urban Dental
School Setting. J Oral Maxillofac Surg, 76, 933-938.
BODIN, I., JULIN, P. & THOMSSON, M. 1981. Hyperodontia. III.
Supernumerary anterior teeth. Dentomaxillofac Radiol, 10, 35-42. MITCHELL, L. & BENNETT, T. G. 1992. Supernumerary teeth
causing delayed eruption--a retrospective study. Br J Orthod, 19,
BROOK, A. H. 1974. Dental anomalies of number, form and size:
41-6.
their prevalence in British schoolchildren. J Int Assoc Dent Child,
5, 37-53. PRIMOSCH, R. E. 1981. Anterior supernumerary teeth--assess-
ment and surgical intervention in children. Pediatr Dent, 3, 204-15.
CHAWLA, O. & ATACK, N. 2012. The management of unerupted
maxillary incisors. Faculty Dental Journal, 3, 208-209. PROFFIT, W. R., FIELDS, H. W., LARSON, B. & SARVER, D. M.
2018. Contemporary orthodontics, Elsevier Health Sciences.
COBOURNE, M. T., FLEMING, P. S., DIBIASE, A. T. & AHMAD,
S. 2012. Clinical cases in orthodontics, John Wiley & Sons. RAJAB, L. D. & HAMDAN, M. A. 2002. Supernumerary teeth:
review of the literature and a survey of 152 cases. Int J Paediatr
DI BIASE, D. D. 1969. Midline supernumeraries and eruption of
Dent, 12, 244-54.
the maxillary central incisor. Dent Pract Dent Rec, 20, 35-40.
SCHEINER, M. A. & SAMPSON, W. J. 1997. Supernumerary teeth:
FLEMING, P. S., XAVIER, G. M., DIBIASE, A. T. & COBOURNE,
a review of the literature and four case reports. Aust Dent J, 42,
M. T. 2010. Revisiting the supernumerary: the epidemiological and
160-5.
molecular basis of extra teeth. Br Dent J, 208, 25-30.
SEEHRA, J., YAQOOB, O., PATEL, S., O’NEILL, J., BRYANT, C.,
FOSTER, T. D. & TAYLOR, G. S. 1969. Characteristics of supernu-
NOAR, J. & COBOURNE, M. King’s Research Portal.
merery teeth in the upper central incisor region. Dent Pract Dent
Rec, 20, 8-12. SEEHRA, J., YAQOOB, O., PATEL, S., O’NEILL, J., BRYANT, C.,
NOAR, J., MORRIS, D. & COBOURNE, M. T. 2018. National clini-
GARVEY, M. T., BARRY, H. J. & BLAKE, M. 1999. Supernumerary
cal guidelines for the management of unerupted maxillary incisors
teeth--an overview of classification, diagnosis and management. J
in children. Br Dent J, 224, 779-785.
Can Dent Assoc, 65, 612-6.
SHAH, A., GILL, D. S., TREDWIN, C. & NAINI, F. B. 2008. Diag-
HE, D., MEI, L., WANG, Y., LI, J. & LI, H. 2017. Association
nosis and management of supernumerary teeth. Dent Update, 35,
between maxillary anterior supernumerary teeth and impacted
510-2, 514-6, 519-20.
incisors in mixed dentition. J Am Dent Assoc, 148, 595-603.
SOUTHALL, P. J. & GRAVELY, J. F. 1989. Vertical parallax radiol-
HOGSTROM, A. & ANDERSSON, L. 1987. Complications related
ogy to localize an object in the anterior part of the maxilla. Br J
to surgical removal of anterior supernumerary teeth in children.
Orthod, 16, 79-83.
ASDC J Dent Child, 54, 341-3.
SUBASIOGLU, A., SAVAS, S., KUCUKYILMAZ, E., KESIM, S.,
HYUN, H. K., LEE, S. J., AHN, B. D., LEE, Z. H., HEO, M. S., SEO,
YAGCI, A. & DUNDAR, M. 2015. Genetic background of supernu-
B. M. & KIM, J. W. 2008. Nonsyndromic multiple mandibular
merary teeth. Eur J Dent, 9, 153-158.
supernumerary premolars. J Oral Maxillofac Surg, 66, 1366-9.
TAY, F., PANG, A. & YUEN, S. 1984. Unerupted maxillary anterior
JUNG, Y. H., KIM, J. Y. & CHO, B. H. 2016. The effects of impacted
supernumerary teeth: report of 204 cases. ASDC J Dent Child, 51,

289-94.
TSAI, H. H. 2002. Panoramic radiographic findings of the man-
dibular growth from deciduous dentition to early permanent denti-
tion. J Clin Pediatr Dent, 26, 279-84.
TYROLOGOU, S., KOCH, G. & KUROL, J. 2005. Location, com-
plications and treatment of mesiodentes--a retrospective study in
children. Swed Dent J, 29, 1-9.
WITSENBURG, B. & BOERING, G. 1981. Eruption of impacted
permanent upper incisors after removal of of supernumerary teeth.
Int J Oral Surg, 10, 423-31.
YAQOOB, O., O’NEILL, J., GREGG, T., NOAR, J., COBOURNE,
M. & MORRIS, D. 2010. Management of unerupted maxillary
incisors. Available from: www http://www. rcseng. ac. uk/fds/
publications-clinical-guidelines/clinical_guidelines/docu-ments/
ManMaxIncisors2010. pdf.[Accessed June 2012].

Impacted Maxillary
Central Incisor
23
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Lubna Almuzian
In this Chapter
1. Incidence of unerupted central incisor 16. Advantage of autotransplantation
2. Aetiology of unerupted central incisor 17. Risks and disadvantage of autotransplantation
3. Effects of unerupted central incisor 18. Factors effecting success of autotransplantation
4. Diagnosis of unerupted central incisor 19. Success rate of autotransplantation
5. Considerations during treatment planning 20. Prognosis of autotransplantation
6. The correlation between dilacerated and impac 21. Management of ankylosed maxillary incisors
tion of incisors 22. Evidence summary
7. Types of tooth dilacerations 23. EXAM NIGHT REVIEW
8. Methods for space creation to allow spontane
ous eruption
9. Extraction/removal of physical obstruction
10. Watchful waiting or mechanical traction?
11. Open surgical exposure techniques
12. Closed surgical exposure techniques
13. Open versus closed exposure techniques
14. Surgical extraction and coronectomy
15. Auto-transplantation
D elayed eruption of permanent maxillary incisors can be
• Gingival fibromatosis.
According to Becker, the aetiology of impacted maxillary
defined if any of the following conditions are met (Seehra et
al., 2018a): central incisors can also be divided into obstructive or trau-
matic causes (Becker, 2013):
• The contralateral maxillary central incisor is delayed
by more than 6 months A. Obstructive causes
• Maxillary incisors remain unerupted more than 1 • Supernumerary teeth

year, after the lower incisors have erupted. • Odontomas
• Unerupted central incisor with closed root apex. • Ectopic position of the tooth bud
• Normal teeth eruption sequence is disturbed, for B. Traumatic causes
example lateral incisor have erupted before central
• Obstruction due to soft tissue repair and scaring
incisor
• Dilaceration
Incidence of unerupted central incisor
• Arrested root development
In summary:
• Acute traumatic intrusion (intrusive luxation)
• Permanent maxillary central incisors are the third
most commonly impacted tooth after the third per- Effects of unerupted central incisor
manent molars and maxillary canines.
These include:
• The incidence of unerupted central incisor is 0.04
• Compromised dentofacial appearance, difficulty in
-2.6 % (Grover and Lorton, 1985, MacPhee, 1935, Di
social interaction and low self-esteem (Shaw et al.,
Biase, 1969).
1991).
• Male to female ratio is 2.7:1 (Bartolo et al., 2010).
• Functional problems including incising food and
• There is frequent association of unerupted central speech difficulties, particularly in the pronunciation
incisors with other dental anomalies, such as ectopic of sound ‘s’ (Weinberg, 1968).
teeth, supernumerary teeth and enamel hypoplasia
Diagnosis of unerupted central incisor
(Bartolo et al., 2010).
These include:
Aetiology of unerupted central incisor
A. Comprehensive medical and dental history (Seehra et al.,
Aetiology is multifactorial with both hereditary and environ-
2018b) is crucial especially for:
mental factors involved:
• Cleft lip and palate patients,
A. Environmental factors
• Patients with craniofacial syndrome (e.g. Cleidocra-
• Early loss of primary teeth with or without loss of
nial dysostosis (CCD) and Gardner’s syndrome).
space in the arch.
• Patient with a history of trauma to primary teeth
• Over-retained primary teeth.
B. Clinical examination such as:
• History of previous trauma and subsequent dilac-
eration of permanent incisor, usually labial crown 1. Palpation to assess the presence of labial or palatal bulgi-
dilacerations of the incisors. ness and
• Localized pathology (cyst formation) 2. Visual clinical assessment to determine:
B. Hereditary factors • Clinical condition of the retained primary teeth and
the adjacent teeth (colour and mobility)
• Physical obstruction due to supernumerary teeth
(28-60%) (Tay et al., 1984), • Position of adjacent teeth (angulation and inclina-
tion) (Tay et al., 1984)
• Cleft lip and palate (Paradowska-Stolarz et al., 2014),
• Presence of arch length discrepancy, spacing, rota-
• Association with other syndromes i.e. Cleidocranial
tions in the labial segment (Moyers, 1976).
dysplasia (CCD), Gardner’s syndrome (Suri et al.,
2004) C. Radiographic examination such as:
• Abnormal tooth/tissue ratio. • Panoramic radiograph.
IMPACTED MAXILLARY CENTRAL INCISOR 237

• Long beam periapical radiograph and/ or upper mas are associated with failure of eruption of the associated
standard occlusal (Jacobs, 1999). Most of the cases teeth (Katz, 1989).
require horizontal or vertical parallax to determine
• Root formation stage of impacted central incisor:
the bucco-lingual position of the unerupted tooth.
This factor has a controversial effect but is mainly
• Lateral cephalogram. related to root dilaceration (Foley, 2004, Di Biase,
1971), (Seehra et al., 2018a) (Leyland et al., 2006)
• CBCT: If conventional radiographs fail to provide
the required information (root resorption, rota- The correlation between dilacerated and impaction of inci-
tion of teeth), CBCT might be prescribed (Grauwe, sors
2018).
These include:
Considerations during treatment planning
• Mildly dilacerated incisors may be brought into the
These include: line of the arch following exposure and application
of orthodontic traction.
A. Patient-related factors such as:
• Potential benefits of aligning an impacted and dilac-
• Medical history: Medical conditions can potentially
erated incisors are improved dental aesthetics and
impact orthodontic and/or surgical treatment plans,
psychosocial benefits, and the preservation of the
for example, bleeding disorders.
alveolar bone (Sandler and Reed, 1988).
• Age and patients’ compliance: The optimal timing
• It has also been reported that dilacerated permanent
for intervention is not precise; some recommend an
maxillary incisors take a longer time to align suc-
intervention at the period between 8-9 years (Ley-
cessfully and have a poorer prognosis for a success-
land et al., 2006). For cases in which a supernumer-
ful eruption (Becker and Chaushu, 2015).
ary tooth caused an impaction of the maxillary inci-
sors, it is believed that too early intervention might • The success rate of an impacted dilacerated tooth
affect the tooth development (Seehra et al., 2018a). alignment mainly depends on the following factors
On the other hand, delayed interception might re- (Topouzelis et al., 2010):
duce the chance for the spontaneous eruption of the
1. The position and direction of the impacted tooth
incisor (Leyland et al., 2006). Some report patient
age as a non-significant factor in determining spon- 2. The degree of root formation
taneous eruption (Di Biase, 1971).
3. The degree and position of dilaceration
• Local factors such as the amount of keratinised gin-
4. The availability of space for the impacted tooth.
giva
Types of tooth dilacerations
B. Local related factors such as:
There are two types of dilacerations, coronal or radicular
• Retained primary teeth: Any retained primary tooth
(root); the former has a better prognosis than the radicular
should be extracted during the surgical exposure of
type. A tooth with radicular dilacerations, at the cervical
the impacted tooth.
third of the root, close to the alveolar crest combined with
• Arch length discrepancy, spacing, rotations in the an incomplete root formation, has a good prognosis for orth-
labial segment (Moyers, 1976) odontic traction. Similarly, radicular dilacerations situated in
the apical third of the root should have a good prognosis; it
• Position of the impacted incisor in three planes of
may require an apicectomy. The most critical type of dilacera-
space influences both successful spontaneous erup-
tion is one close to the CEJ; the prognosis of the aligned tooth
tion and overall treatment duration (Chaushu et al.,
is extremely poor, which may require extraction.
2015). The higher the vertical position, the less likely
the tooth to erupt spontaneously after the obstruc- Methods for space creation to allow spontaneous eruption
tion is removed
According to RCT (Pavoni et al., 2013a), rapid maxillary ex-
• Nature/type of physical obstruction (hard tissue or pansion following surgical removal of the obstruction is an
soft tissue obstruction) including: effective interceptive method in 82% of the cases. In 39% of
the controlled group, removal of the obstruction alone re-
1. Tuberculate supernumerary teeth and odontomas are
sulted in an eruption of the impacted incisor. The concern
more likely to obstruct permanent maxillary incisor eruption
in this study is the controversial use of rapid expansion at an
than conical supernumerary teeth (Leyland et al., 2006).
early age in the absence of crossbite. In a cohort study by Pa-
2. One-third of compound and one-half of complex odonto- voni (Pavoni et al., 2013b), it was reported that teeth erupt
238 IMPACTED MAXILLARY CENTRAL INCISOR

spontaneously after removal of the obstruction when the im- It involves:
pacted incisor is at a 30° angle to the midsagittal plane, or
• Simple elliptical incision is rarely used but valuable
when it is located at the gingival third of the root of the con-
in soft tissue impaction
tralaterally erupted tooth. But when the angulation is 30-60°,
and the vertical level is at the middle third of the root of the • Surgical window/gingivectomy: A surgical window
contralateral tooth, it is recommended that rapid maxillary or gingivectomy is suggested for shallow, labially po-
expansion is used to aid spontaneous eruption. On the other sitioned maxillary incisor impactions, close to the
hand, spontaneous eruption chances are minimal once the alveolar crest, or a broadband of keratinised tissue
angulation exceeds 60° and the tooth is in the apical third of is present (Kokich and Mathews, 1993). A gingivec-
the adjacent erupted tooth. In such cases, surgical exposure, tomy procedure is indicated when one half to 2/3rd
removal of obstruction and orthodontic traction are needed. of the crown can be uncovered, leaving at least 3 mm
of an attached gingival collar. In most instances, the
Extraction/removal of physical obstruction
tip of the impacted tooth is near the cementoenamel
Extraction of supernumerary teeth is associated with 49- junction of the adjacent tooth. This technique is sim-
91% of the spontaneous eruption of the impacted maxillary ple, but it sacrifices the attached gingiva (Kokich and
incisor (Leyland et al., 2006, Foley, 2004). However, 30-54% Mathews, 1993). Gingivectomy is contraindicated if
still require surgical intervention (Seehra et al., 2018b). For the cervical-enamel junction of the impacted tooth
patients younger than 9 years with a developing permanent is within alveolar mucosa
maxillary incisor, their spontaneous eruption on average can
• Apically repositioning flap is used when there is
take up to 9–12 months after the removal of an obstruction
a risk of gingival attachment loss (Chaushu et al.,
(Pavoni et al., 2013a). Spontaneous eruption time can even
2009). The main indication for this procedure is
take up to 18 months. For patients younger than 9 years, it is
when a labially impacted tooth is situated above the
important to avoid surgical traumatising of the tooth follicle
level of the mucogingival junction but not displaced
of the impacted incisor.
mesially or distally. It is used primarily for labial
There is a lack of evidence whether, at the time of obstruc- impactions due to the inability to apically reposi-
tion removal, the incisor should be exposed or left as such to tion the palatal field (Vanarsdall and Corn, 1977). It
allow for spontaneous eruption (Chaushu et al., 2015). For involves raising a labial mucogingival flap from the
simplicity, it is possible to summarise the intervention using crest of the ridge and re-suturing it at the cervical
two acronyms (Seehra et al., 2018a): aspect, leaving the crown exposed. Mostly a partial
thickness flap is used.
• SET for patient older than 9 years: Space creation,
Extraction of obstruction, and Traction of the im- • One of the advantages of apically repositioning flap
pacted tooth mechanically, or is that it increases the amount of attached gingiva
Field (Seehra et al., 2018b). However, it might in-
• SEWT for under the age of 9 years: Space creation,
crease incisor clinical crown length and poor soft
Extraction of obstruction, Watchful waiting for
tissue aesthetics (Chaushu et al., 2009).
spontaneous eruption, and Traction of the impacted
tooth mechanically, if fails to erupt spontaneously). Closed surgical exposure techniques
Watchful waiting or mechanical traction? It involves:
Recent guidelines recommend watchful waiting for the 1. Technique and attachments: In this technique, a full-
spontaneous eruption of the impacted tooth after surgical thickness (mucoperiosteal) flap is raised with avoidance of
removal of the physical obstruction for patients younger incisor follicle removal, and attachment is bonded on the
than 9 years of age with under-developed/immature teeth exposed incisor, then the flap is sutured into the original
(Seehra et al., 2018a). Some consider it efficient to bond an position. Low profile attachment is preferred, which can be
attachment on the impacted tooth at the time of surgical bonded to the palatal surface of the impacted incisor (Seehra
intervention and obstruction removal even if the root still et al., 2018b). An impacted incisor with a thin cortical bone
developing (under the age of 9 years); the attachment can be or bone dehiscence has a high potential for gingival recession
used for orthodontic traction at a later stage if spontaneous (Vandenberghe et al., 2007)(Almuzian et al., 2015).
eruption fails, thus avoiding the need for a second surgical
2. Mechanical traction: As a general principle, no physi-
intervention (Seehra et al., 2018b). Surgical exposure and
cal obstruction by the adjacent root should be present in the
orthodontic traction of unerupted incisors have a success
direction of traction; otherwise resorption of the adjacent
rate greater than 90% (Davies et al., 2008).
roots and/or failure of eruption can occur. For adults or ad-
Open surgical exposure techniques (open eruption) olescents, mechanical traction to the tooth should be com-

menced on the day of surgery. Traction forces should be low These include:
and should not exceed more than 2 ounces or 60 grams (Sukh
• Physiological tooth (Czochrowska et al., 2000)
et al., 2014). Traction force can be applied through the use
of removable or fixed appliances. The removable appliance • Maintenance of alveolar bone
might include magnets embedded in a Hawley appliance or
• Good long-term survival rates.
a modified Hawley appliance with anterior hooks and elas-
tics support. Fixed mechanics can be used such as piggyback Risks and disadvantages of autotransplantation
mechanics, TMA fishing rods, mini implants, TPA appliance These include:
with ballista spring, intermaxillary elastics supported by
a lower arch, elastic thread extended to the main archwire, • Ankylosis and eruption failure (Yaqoob et al., 2010,
slingshot mechanics using power chain supported by section- Seehra et al., 2018b)
al or full fixed appliance, etc. • Poor morphology
Open versus closed exposure (eruption) techniques • Requirement of extensive reshaping and restorative
The open exposure approach is associated with a 1.37mm lon- treatment
ger clinical crown, abnormal gingival contour and decreased •
Maxillary canine displacement is a common
bone support with 7.5% less bone support on the mesial side (Chaushu et al., 2003b)
of the affected tooth than with a closed technique (Chaushu
et al., 2003a, Chaushu et al., 2009). On the other hand, the • Static and dynamic occlusal disturbance due to the
close eruption is perceived as better in gingival, periodontal presence of palatal cusp,
and pulpal status than open exposure. However, there is no • External root resorption.
evidence comparing closed or open eruption techniques for
an impacted maxillary central incisor, though a systematic • Premature loss of a transplanted tooth.
review conducted for palatally impacted canine shows low- Factors affecting the success of autotransplantation
quality evidence of no difference between the two techniques
(Parkin et al., 2017). These include:
Surgical extraction of the impacted incisor and coronec- 1. Root development and status such as:
tomy • 1/3rd to 2/3rd of the root of the donor’s teeth should
Extraction and coronectomy of unerupted incisor can be be formed. If the root development of donor’s teeth
considered in the presence of: is more significant than 3/4rd, the root canal of the
teeth should be done within 10 days of transplanta-
• Severe dilaceration or coronal dilaceration tion.
• Ankylosis • Atraumatic extraction of donor’s teeth
• Severe infra-occlusion • Intact periodontium of the donor’s tooth
• Space closure in the mixed dentition, followed by • Minimum invasive surgery for an impacted tooth
space reopening in the permanent dentition to gain removal.
bone volume
2. Post-transplantation splinting and stabilisation: After
Surgical extraction or auto-transplantation transplantation, splinting of the transplanted teeth for 7-14
Autotransplantation helps preserve the bone at the extraction days using bonded flexible wire is essential. Splinting can also
side and stimulate bone growth by the eruption of the trans- be done with orthodontic brackets if other malocclusion fea-
planted tooth. tures need to be corrected, but appliances should be passive
on the transplanted tooth. If orthodontic brackets are bonded
Autotransplantation of premolars is a viable method for re- for splinting, there should be enough gap between the gingiva
placing maxillary central incisors with an excellent long-term and bracket, so the patient can easily clean the area above the
survival (Stange et al., 2016). Ideally, the lower second pre- bracket.
molar can be auto-transplanted at the upper central incisors
position where extractions of the lower arch are indicated for Success rate of autotransplantation
orthodontic reasons (Kvint et al., 2010). Premolars should be The success rate for premolar transplant has been reported
rotated by 90° to increase the mesiodistal width and improve from 81-98% (Kvint et al., 2010, Kristerson and Lagerstrom,
gingival aesthetics. 1991, Czochrowska et al., 2000, Andreasen et al., 1990). Only
Advantages of autotransplantation one study reported a 100% success rate, but only four premo-
lar cases were included in the study (Slagsvold and Bjercke,

1978). b) Children aged nine years (complete or nearly complete
Prognosis of autotransplantation apex)
The prognosis of autotransplantated tooth depends upon: • Follow stages 1-3
• Root maturation status, • Monitor eruption for 12 months
• Surgical exposure and skills of the surgeon • If spontaneous eruption fails, then expose, bond and
align.
• Type and height of periodontal attachment
c) Children older than 10 years)
• Surgical treatment duration
• Follow stages 1-3 o
• Relative crestal bone height of alveolus
• Expose, bond, and align
• Preservation of vitality
• Oral hygiene
Management of ankylosed maxillary incisors
Although no evidence is available for ideal management of
ankylosed maxillary incisors, the available options are:
Case Example
Diagnostic summary
• Periodic follow up with or without build-ups for mi-
nor infra-occlusion H.A a 21 years old healthy male presented with missing up-
per right central incisor on permanent dentition with class
• Surgical luxation of the incisor combined with orth-
I incisors relationship, on Class I skeletal relationship on
odontic traction
average vertical proportions, complicated by impacted and
• Surgical repositioning (osteotomy of dentoalveolar ankylosed right maxillary central incisor.
segment and repositioning or distraction osteogen-
The patients has no facial asymmetry, competent lips, opti-
esis of the segment)
mal incisor show on smile and rest. Intraorally he had Class
• Extraction followed by space closure I molars and canine relations bilaterally.
• Extraction followed by prosthetic tooth (implant/
bridge)
Variable Norms T0
• Extraction followed by reimplantation
SNA 83° ± 3 ° 80°
• For growing patients, decoronation can be consid- SNB 79°± 3 ° 77°
ered to preserve the alveolar bone (Malmgren, 2000)
ANB 3°± 2 3°
MMPA 27+5° 24°
The recommendations of the Royal College of Surgeon FACE HEIGHT 55% + 2 56%
of England for unerupted incisors with supernumerary RATIO
teeth impeding the eruption
SN TO Maxillary 8+3° 8°
Below is a summary of the guideline (Seehra et al., 2018): plane
a) Children younger than nine years (incomplete root de- Upper incisors to 109± 5 92°
velopment of permanent incisor) maxillary plane
Lower incisors to 96°± 5 105
1. Create space if require
mandibular plane
2. Maintain the space Interincisal angle 135± 10 136°
3. Remove supernumerary tooth atraumatically Wits appraisal 0.mm -1mm
4. Monitor eruption for 18 months with or without mini- Lower incisor to 0-2 mm 1mm
mal soft tissue exposure. If exposed, wait 6 months Apo line
5. If spontaneous eruption fails, then expose, bond and
align.

ankylosis can be confirmed with the use of a high definition
CBCT. Ankylosis can be definitely confirmed at the time of
exposure with assessment of mobility and negative response
to mechanical traction. A recent technique involves the uses
of Doppler system.
How do you plan your anchorage demand in this cases?
Anchorage planning should be in 3 planes of spaces, in this
case, considering position of the impacted incisor, vertical
anchorage using heavy archwire for traction of the impacted
tooth (0.021” x 0.025” S/S, 0.019” x 0.025” S/S, transpalatal
appliance, Nance button appliance or TAD) are recommend-
ed, to avoid bowing of the occlusal plane,
Can the lower arch be utilised to provide vertical anchor-
age?
Yes, box elastics supported with heavy lower archwire
(0.019” x 0.025”) can be utilised to extrude the impacted
tooth. It is essential to bond the lower second molars to
increase vertical anchorage value of lower arch.
Why subluxation is the preferred option over distraction
osteogenesis for ankylosed teeth?
Surgical luxation is relatively less invasive and simple. How-
ever, one of the potential complications secondary to sublux-
ation or distraction osteogenesis are intrusion of adjacent
What you would ask in the history assessment? teeth, inflammation/infection, resorption, ankylosis and
It is important to undertake a comprehensive history evalua- poor gingival contour/margins.
tion of any dentofacial trauma along with a detailed descrip- What is the chance spontaneous eruption of central inci-
tion of nature of trauma if possible. Chronological age and sor following space creation in this case?
status of eruption at the time of trauma should be identified,
signs and symptom of pain, pus discharge should be noted Considering the history of dentoalveolar trauma, oblitera-
as well. tion of PDL space and root developmental stage of the
impacted incisor, spontaneous eruption is highly unlikely.
How does the information from the trauma history affect
the long term prognosis of the impacted tooth? Does extraction of impacted incisor and space closure an
option in this case?
With positive history of intrusive dentoalveolar trauma,
moderate to severe intrusion and obliteration of PDL on As the case presented with Class I skeletal basis, Class I
DPT (though poor representative) and/ or ankylosis is molar and Class I canine relationships, reduced overjet and
highly likely. in absence of crowding, space closure would be unfavour-
able option.
What features you would like to screen using the DPT?
What type of surgical exposure would be recommended
Morphology of the root, obliteration of PDL space, dilacera- in this case?
tions of root and proximity of the adjacent teeth and roots.
The relationship between the position of incisal edge of the
What other radiographical images might be required? impacted tooth and the mucogingival junction is the key
In addition to digital manual palpation, 2D or 3D radio- variable for decision making, accordingly, closed eruption
graphical images might be required for localisation of tooth technique would be the option of choice.
and assessment of ankylosis. What retention regime would be suitable for this case?
How to diagnose ankylosis of root of central incisor? Fixed flexible bonded retainer supported with night wear of
Change in the colour of the tooth, metal sound on percus- either Hawley or thermoplastic retainer are recommended.
sion, obliteration of PDL space as seen on the radiograph
are suggestive ways of diagnosis, though some claimed that

Exam night review esis of the segment),
Incidence: 3rd most commonly impacted tooth. • Extraction followed by space closure,
• Unerupted central incisor is 0.04 -2.6 % (Grover and • Extraction followed by Prosthesis (implants),
Lorton, 1985, MacPhee, 1935, Di Biase, 1969).
• Extraction followed by reimplantation, or
• Male to female ratio is 2.7:1 (Bartolo et al., 2010).
• For growing patients, decoronation can be con-
Aetiology (Becker, 2013). sidered to preserve the alveolar bone (Malmgren,
2000).
• Supernumerary teeth
• Odontomas
• Ectopic position of the tooth bud.
• Obstruction due to soft tissue repair and scaring,
• Dilaceration,
• Arrested root development
• Acute traumatic intrusion (intrusive luxation)
Open surgical exposure techniques (open eruption)
• Simple elliptical incision
• Surgical window/ gingivectomy
• Apically repositioning flap
Advantage of autotransplantation (Czochrowska et al.,
2000):
• Physiological tooth
• Maintenance of alveolar bone
• Good long-term survival rates.
Risks and disadvantages of autotransplantation (Yaqoob
et al., 2010, Seehra et al., 2018b)
• Ankylosis and eruption failure
• Poor morphology
• Needs extensive reshaping and restorative work
•
Maxillary canine displacement is a common
(Chaushu et al., 2003b)
• Problem with functional occlusion due to presence
of palatal cusp
• External root resorption
• Premature loss of a transplanted tooth.
Management of ankylosed maxillary incisors
• Periodic follow up with or without build-ups for mi-
nor infra-occlusion,
• Surgical laxation of the incisor combined with orth-
odontic traction,
• Surgical repositioning (osteotomy of dentoalveolar
segment and repositioning or distraction osteogen-

mas. ASDC J Dent Child, 56, 445-9.
References KOKICH, V. G. & CRABILL, K. E. 2006. Managing the patient with
missing or malformed maxillary central incisors. Am J Orthod
ALMUZIAN, M., FREEL, J., CROSS, N. & GARDNER, A. 2015. A
Dentofacial Orthop, 129, S55-63.
novel approach for treatment of the impacted maxillary incisor. J
Orthod, 42, 144-52. KOKICH, V. G. & MATHEWS, D. P. 1993. Surgical and orth-
odontic management of impacted teeth. Dent Clin North Am, 37,
ANDREASEN, J. O., PAULSEN, H. U., YU, Z., AHLQUIST, R.,
181-204.
BAYER, T. & SCHWARTZ, O. 1990. A long-term study of 370 au-
totransplanted premolars. Part I. Surgical procedures and standard- KRISTERSON, L. & LAGERSTROM, L. 1991. Autotransplantation
ized techniques for monitoring healing. Eur J Orthod, 12, 3-13. of teeth in cases with agenesis or traumatic loss of maxillary inci-
sors. Eur J Orthod, 13, 486-92.
BARTOLO, A., CAMILLERI, A. & CAMILLERI, S. 2010. Unerupt-
ed incisors--characteristic features and associated anomalies. Eur J KVINT, S., LINDSTEN, R., MAGNUSSON, A., NILSSON, P. &
Orthod, 32, 297-301. BJERKLIN, K. 2010. Autotransplantation of teeth in 215 patients. A
follow-up study. Angle Orthod, 80, 446-51.
BECKER, A. 2013. Orthodontic treatment of impacted teeth, CRC
Press. LEYLAND, L., BATRA, P., WONG, F. & LLEWELYN, R. 2006. A
retrospective evaluation of the eruption of impacted permanent
BECKER, A. & CHAUSHU, S. 2015. Etiology of maxillary canine
incisors after extraction of supernumerary teeth. J Clin Pediatr
impaction: a review. Am J Orthod Dentofacial Orthop, 148, 557-67.
Dent, 30, 225-31.
CHAUSHU, S., BECKER, T. & BECKER, A. 2015. Impacted central
MACPHEE, C. 1935. The incidence of erupted supernumerary
incisors: factors affecting prognosis and treatment duration. Am J
teeth in consecutive series of 4000 school children. Br Dent J, 58,
59-60.
CHAUSHU, S., BRIN, I., BEN-BASSAT, Y., ZILBERMAN, Y. &
MALMGREN, B. 2000. Decoronation: how, why, and when? J Calif
BECKER, A. 2003a. Periodontal status following surgical-orth-
Dent Assoc, 28, 846-54.
odontic alignment of impacted central incisors with an open-erup-
tion technique. Eur J Orthod, 25, 579-84. MCDOWALL, R. J., YAR, R. & WARING, D. T. 2012. 2 ‘2’ 1: Orth-
odontic repositioning of lateral incisors into central incisors. Br
CHAUSHU, S., DYKSTEIN, N., BEN-BASSAT, Y. & BECKER, A.
Dent J, 212, 417-23.
2009. Periodontal status of impacted maxillary incisors uncovered
by 2 different surgical techniques. J Oral Maxillofac Surg, 67, 120-4. MOYERS, R. E. 1976. Standards of human occlusal development.
CHAUSHU, S., ZILBERMAN, Y. & BECKER, A. 2003b. Maxillary PARADOWSKA-STOLARZ, A., DUBOWIK, M., SZELĄG, J. &
incisor impaction and its relationship to canine displacement. Am J KAWALA, B. 2014. Dental anomalies in the incisor-canine region
Orthod Dentofacial Orthop, 124, 144-50; discussion 150. in patients with cleft lip and palate - literature review. Dev Period
Med, 18, 66-9.
CZOCHROWSKA, E. M., STENVIK, A., ALBUM, B. & ZACHRIS-
SON, B. U. 2000. Autotransplantation of premolars to replace max- PARKIN, N., BENSON, P. E., THIND, B., SHAH, A., KHALIL, I.
illary incisors: a comparison with natural incisors. Am J Orthod & GHAFOOR, S. 2017. Open versus closed surgical exposure of
Dentofacial Orthop, 118, 592-600. canine teeth that are displaced in the roof of the mouth. Cochrane
Database Syst Rev, 8, Cd006966.
DAVIES, C., HARRISON, M. & ROBERTS, G. 2008. UK national
clinical guidelines in paediatric dentistry: guideline for the use of PAVONI, C., FRANCHI, L., LAGANA, G., BACCETTI, T. &
general anaesthesia (GA) in paediatric dentistry. London: Royal COZZA, P. 2013a. Management of impacted incisors following
College of Surgeons of England. surgery to remove obstacles to eruption: a prospective clinical trial.
Pediatr Dent, 35, 364-8.
DI BIASE, D. D. 1969. Midline supernumeraries and eruption of
the maxillary central incisor. Dent Pract Dent Rec, 20, 35-40. PAVONI, C., FRANCHI, L., LAGANA, G. & COZZA, P. 2013b.
Radiographic assessment of maxillary incisor position after rapid
DI BIASE, D. D. 1971. The effects of variations in tooth morphol-
maxillary expansion in children with clinical signs of eruption
ogy and position on eruption. Dent Pract Dent Rec, 22, 95-108.
disorder. J Orofac Orthop, 74, 468-79.
FOLEY, J. 2004. Surgical removal of supernumerary teeth and the
PRATHYUSHA, P., JYOTI, S., KAUL, R. B. & SETHI, N. 2011.
fate of incisor eruption. Eur J Paediatr Dent, 5, 35-40.
Maryland Bridge: An Interim Prosthesis for Tooth Replacement in
GROVER, P. S. & LORTON, L. 1985. The incidence of unerupted Adolescents. Int J Clin Pediatr Dent, 4, 135-8.
permanent teeth and related clinical cases. Oral Surg Oral Med
SANDLER, P. J. & REED, R. T. 1988. Treatment of a dilacerated
Oral Pathol, 59, 420-5.
incisor. J Clin Orthod, 22, 374-6.
JACOBS, S. G. 1999. Radiographic localization of unerupted
maxillary anterior teeth using the vertical tube shift technique: the
NOAR, J., MORRIS, D. & COBOURNE, M. 2018a. National clini-
history and application of the method with some case reports. Am
cal guidelines for the management of unerupted maxillary incisors
in children. British dental journal, 224, 779-785.
KATZ, R. W. 1989. An analysis of compound and complex odonto-

NOAR, J., MORRIS, D. & COBOURNE, M. T. 2018b. National
clinical guidelines for the management of unerupted maxillary
incisors in children. British Dental Journal, 224, 779-785.
SHAW, W. C., O’BRIEN, K. D., RICHMOND, S. & BROOK, P.
1991. Quality control in orthodontics: risk/benefit considerations.
Br Dent J, 170, 33-7.
SLAGSVOLD, O. & BJERCKE, B. 1978. Applicability of autotrans-
plantation in cases of missing upper anterior teeth. Am J Orthod,
74, 410-21.
STANGE, K. M., LINDSTEN, R. & BJERKLIN, K. 2016. Autotrans-
plantation of premolars to the maxillary incisor region: a long-term
follow-up of 12-22 years. Eur J Orthod, 38, 508-15.
SUKH, R., SINGH, G. P. & TANDON, P. 2014. Interdisciplinary
approach for the management of bilaterally impacted maxillary
canines. Contemp Clin Dent, 5, 539-44.
SURI, L., GAGARI, E. & VASTARDIS, H. 2004. Delayed tooth
eruption: pathogenesis, diagnosis, and treatment. A literature
review. Am J Orthod Dentofacial Orthop, 126, 432-45.
TAY, F., PANG, A. & YUEN, S. 1984. Unerupted maxillary anterior
supernumerary teeth: report of 204 cases. ASDC J Dent Child, 51,
289-94.
TOPOUZELIS, N., TSAOUSOGLOU, P., PISOKA, V. & ZOULOU-
MIS, L. 2010. Dilaceration of maxillary central incisor: a literature
review. Dent Traumatol, 26, 427-33.
VANARSDALL, R. L. & CORN, H. 1977. Soft-tissue management
of labially positioned unerupted teeth. Am J Orthod, 72, 53-64.
VANDENBERGHE, B., JACOBS, R. & YANG, J. 2007. Diagnostic
validity (or acuity) of 2D CCD versus 3D CBCT-images for assess-
ing periodontal breakdown. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod, 104, 395-401.
WEINBERG, B. 1968. A cephalometric study of normal and defec-
tive -s- articulation and variations in incisor dentition. J Speech
Hear Res, 11, 288-300.
YAQOOB, O., O’NEILL, J., GREGG, T., NOAR, J., COBOURNE,
M. & MORRIS, D. 2010. Management of unerupted maxillary
incisors. Available from: www http://www. rcseng. ac. uk/fds/
publications-clinical-guidelines/clinical_guidelines/docu-ments/
ManMaxIncisors2010. pdf.[Accessed June 2012].

Impacted Canine
24
Written by: Mohammed Almuzian, Haris Khan,Maham Munir, Abbas Naseem
In this Chapter
1. Prevalence and Incidence 17. Type of surgical exposure
2. Development and eruption of maxillary canines 18. Mechanical eruption of the impacted canine
3. Aetiology of impacted canines 19. Indications for surgical removal
4. Recent classification 20. Indication of transalveolar autotransplant
5. Theories of palatally impacted canines 21. Indication of surgical repositioning
6. Classification of impacted maxillary canines 22. Causes of poor outcome
7. Consequences of an impacted canine 23. Impacted mandibular canine
8. Investigations and diagnosis 24. EXAM NIGHT REVIEW
9. Magnification technique
10. Parallax Technique
11. Sectors classification
12. Risk factors for resorption of lateral roots
13. Management and treatment
14. Interceptive treatment
15. Guidelines for interceptive treatment
16. Surgical exposure and orthodontic alignment
A canine is considered impacted if: canine erupts into position, the physiological median dia-
stema closes (Becker, 1978). The maxillary canine should be
• It is unerupted after three quarters root develop- palpable in the buccal sulcus by the age of 10 years (Ferguson,
ment (Litsas and Acar, 2011). 1990).
• The contralateral tooth has erupted for at least 6 In general, maxillary canines erupt earlier in females than
months with complete root formation or in males (Wedl et al., 2004) usually at the age of 11-12 years
while the mandibular canine erupts at the age of 10-11 years
• The canine position is intraosseous at or beyond CS5 (Littlewood and Mitchell, 2019) (Brin et al., 1986b). It has
or 2 years after adolescent growth spurt or 6 month been suggested that ectopic canines are associated with de-
after its root completion (Lindauer et al., 1992). layed dental development (Becker and Chaushu, 2000).
Ectopic or displaced canines (DCs) refers to intraosseous Aetiology of impacted canines
or infraosseous position of the canine before the expect-
ed time of the eruption. The aetiology of impacted canines is multifactorial, both envi-
ronmental and genetic factors are purposed for this anomaly.
Prevalence and Incidence
• Path of eruption: The long tortuous path of eruption
In summary: of upper canine, which is about 22mm, increases the
• Maxillary canines are developmentally absent in probability of impaction. Some experts (absence of
0.3% of the population (Brin et al., 1986a). strong evidence) stated that impacted canines are
more common in patient with long face.
• Mandibular canines are developmentally absent in
0.1% of the population (Littlewood and Mitchell, • Obstruction of the path of eruption: Deciduous ca-
2019) nines can be slightly resistant to resorption prevent-
ing the eruption of permanent canines. The presence
• Maxillary canines are second most frequently im- of supernumerary teeth, cyst, fibrous tissue or dense
pacted teeth after mandibular third molar. bone can also obstruct the eruption of the canine
• Impacted canine has incidence of 1.7 to 2% (Ericson leading to impaction.
and Kurol, 1988a, Ericson and Kurol, 1986b). • Arch length discrepancy: Crowding or shortening
• Palatal impaction of canine is the most common of the length of the arch can lead to buccal impac-
61%, followed by the impaction within the line of tion (Jacoby, 1983). Also, in buccal impacted ca-
the arch 34%. While buccal impaction contributes nines, there is usually reduced maxillary intercanine
to 4.5% of the total canine impactions (Stivaros and width and hyperdivergent skeletal relationships.
Mandall, 2000). • Dental anomalies and canine guidance: The canine,
• Unilateral impactions are 4 times more frequent during its eruption takes guidance from the roots of
than bilateral impactions of the canines. lateral incisors. Maxillary lateral incisor anomalies
such as ectopic eruption/ inclination and hypodon-
• Female to male ratio is 7:3 (Mossey et al., 1994). tia or microdontia increases the chances of deviation
• Dachi and Howell (Dachi and Howell, 1961) showed of the canine from its path. A study found that the
that the majority of impacted maxillary canines are incidence of canine impaction is increased to 42.6%
unilateral (92%), and only 8% are bilateral while the if lateral incisors are small or developmentally ab-
female to male ratio is 2:1. sent (Brin et al., 1986b).
• Impacted canines are more frequent in in Class II • Genetic background: Palatal impactions are mostly
div.2 malocclusion (Mossey et al., 1994). due to genetic reasons, this is why it is more com-
mon among some ethnic patient’s, females, twins
Development and eruption of maxillary canines and in certain families (Jacobs, 1996).
The calcification of the canine commences at 4-5 months and Recent classification of aetiology of maxillary canine im-
completes at 5−6 years of age. Canine development occurs paction
at high level in the maxilla, lateral to the piriform fossa, and
has the longest path of eruption (22 mm). Canine migrates These include (Becker and Chaushu, 2015):
forward and downwards to lie buccal and mesial to the apex 1. Local hard tissue obstruction
of the deciduous canine, then continues to move down and
mesially pushes the distal aspect of the root of the upper lat- • Lappin’s theory of over-retained deciduous canine
eral incisor creating a physiological median diastema. As the • Supernumerary teeth and odontoma
248 IMPACTED CANINE

• Abnormal orientation or abnormal root form of the is either horizontal, vertical or semi-vertical.
adjacent first premolar
Class III: Impacted canine located labially and palatally with
2. Local pathology the crown on one side and the root on the other side
• Chronic periapical granuloma associated with over- Class IV: Impacted canine located within the alveolar process.
retained deciduous canines It is usually vertically between the incisor and first premolar
• Displacement of unerupted teeth by radicular cyst Class V: Impacted canine in edentulous maxilla.
formation
2. Becker Classification (Becker, 2007)
• Hydrostatic pressure provided by dentigerous cyst
This classification is based on two variables:
• Dentoalveolar trauma
• The transverse relationship of the crown of the tooth
3. Disturbance of the normal development of the incisors. to the line of the dental arch, which may be close or
distant (nearer the midline).
4. Genetic or hereditary factors
• The height of the crown of the tooth in relation to
Theories of palatally impacted canines
the occlusal plane, which may be defined as high or
The guidance theory as described by Dr Becker: It suggests low.
that the distal aspect of the lateral incisor is the guide for the
canine eruption. Hence, palatally impacted canines were very Group Proximity to the Position in the
closely associated with spaced dentitions, peg -shaped lateral line of the arch maxilla
incisors, microdontia, or congenitally absent lateral incisors. Group 1 Close Low
Approximately half of the cases of palatal impactions that Group 2 Close Forward, low, and
were diagnosed were associated with anomalous lateral inci- mesial to lateral
sors (Becker et al., 1981). incisor root.
The genetic theory as described by Peck et al in 1994: Accord- Group 3 Close High
ing to this theory, palatally impacted canines are concomi-
Group 4 Distant High
tant with other dental anomalies, such as lateral premolar
hypodontia and peg laterals with strong gender, familial and Group 5 Canine root apex mesial to that of
population association. However, this theory is not fully clear lateral incisor or distal to that of first
in explaining the following controversies: premolar.
Group 6 Erupting in the line of the arch, in
• Right-left equivalence is the rule in genetics, yet
place of and resorbing the roots of the
unilateral canine impaction outnumbers bilateral
incisors.
occurrence by 2 or 3 to 1.
Sequelae (Consequences) of an impacted canine
• The parity of its prevalence in monozygous vs dizy-
gous twins is difficult to explain in genetic terms.
Based on the evidence quoted above, it seems clear that the
These include:
determination of the eruption path of the palatal canine is,
for the most part, not under genetic control only. The guid- • Labial or lingual mal-positioning of impacted tooth
ance theory and the genetic theory share the belief that cer- • Migration of neighbouring teeth and resultant loss
tain genetic features occur in association with the cause of of arch length
palatal displacement of the maxillary canine. These include
small, peg-shaped, and missing lateral incisors, spaced denti- • External root resorption of the impacted and neigh-
tions, and late-developing dentitions. bouring teeth
Classification of impacted maxillary canines • Loss of vitality of the incisors can occur
These include: • Infections and dentigerous cyst formation
1. Archer classfication • Referred pain
Class I: Impacted canines in the palate which is either hori- • Damage to adjacent teeth during surgery
zontal, vertical or semi-vertical. • Poor esthetics associated with primary canines
Class II: Impacted canines located on the labial surface which • Ankylosis of impacted canine.
IMPACTED CANINE 249

• Rarely, internal resorption of the canine. index), then the canine is palatally displaced. This
approach was very reliable in which the canine was
Investigations and diagnosis
seen on the film to be superimposed on the coronal
It has been suggested that the following clinical signs might or middle portions of the root of the adjacent incisor
be indicative of canine impaction: (Chaushu et al., 2005).
• Delayed eruption of the permanent canine com- • Canine-Canine index (CCI): The ratio of the wid-
pared to contralateral or the average dental age est mesiodistal dimension of the impacted canine to
that erupted canine (Nagpal et al., 2009). If the im-
• Retention of the deciduous canine beyond 14–15
pacted canine is palatal, it would be larger than the
years of age
erupted contralateral canine.
• Absence of a normal labial canine bulge or a bulge in
The problem for diagnosing the buccolingual position of the
the palatal region of the canine tooth.
impacted canine using a single OPG is that OPG overesti-
•
Delayed eruption, distal tipping, or migration mates the angulation and underestimates the proximity to the
(splaying) of the lateral incisor (Bishara, 1992). midline (Ferguson, 1990). Therefore, the preferred means of
• Loss of vitality and increased mobility of the perma- localisation is the parallax technique.
nent maxillary lateral incisor and central incisor. Parallax Technique
Palpation of the buccal surface of the alveolar process distal Parallax is the apparent displacement of an image of an object
to the lateral incisor from 8 years of age may reveal the posi- of interest relative to the image of a reference object second-
tion of the maxillary canine and has been recommended as ary to an actual change in the angulation of the X-ray beam
a diagnostic tool; however, lack of positive palpation is only (Jacobs, 1999). Parallax technique depends on the principle
considered abnormal after the age of 10 years (Kettle, 1957). of tube-shift technique or Clark’s rule or (SLOB) rule: Same
Hence, practitioners should suspect ectopia if the canine is Lingual Opposite Buccal. The image of the tooth that is fur-
not palpable in the buccal sulcus by the age of 10‑11 years ther away from the X-ray tube moves in the same direction
(Husain et al., 2012). If the canine is not palpable buccally by as the tube, whereas that of the tooth closer to the X-ray tube
9-10 years, then the following investigations should be un- moves in the opposite direction. There are two types of paral-
dertaken (Mittal et al., 2017): lax techniques, horizontal and vertical.
1. Visual clinical assessment inspection of the canine bulge Horizontal parallax can be achieved using:
in which distopalatally inclined lateral incisors may indicate
• Upper standard occlusal and one periapical radio-
palatal impaction while mesiolabially inclined lateral incisors
graph or
may indicate labial impaction. The colour and mobility of the
deciduous canine should also be assessed. • Two periapical radiographs: It was reported that
92% of the palatal canines could be localised using
2. Radiographic assessment using one or a combination of
two periapical (Ericson S & Kurol J 1987).
the following imaging
Vertical parallax can be obtained using:
• Panoramic radiograph (OPG).
• upper standard occlusal radiograph and OPT/ DPT/
• Periapical radiograph.
OPG
• Lateral cephalometric radiograph.
• The upper standard occlusal radiograph has an an-
• Upper standard occlusal radiograph. gulation of 70°‑75° and OPG. OPG and anterior oc-
• CBCT or medical CT scans. clusal radiograph are commonly used, giving a 60°
tube shift approximately as the angulation of the X-
Magnification technique ray beam changes in the vertical plane from 8°, for
Palatal canines often appear magnified on OPG as the palatal an OPG, to 60° for an anterior occlusal (Southall and
canine is nearer to the x-ray source and away from the sen- Gravely, 1987). It has been reported that an increase
sor/film (Chaushu et al., 1999). To localise impacted canines in the vertical angulation of the X-ray tube from 60-
on a single OPG, certain indexes are used: 65° to 70-75° could increase the effectiveness of the
vertical parallax technique (Jacobs, 1999).
•
Canine-to-incisor index: When the mesiodistal
width of the crown of an unerupted canine (as it Armstrong and colleagues (Armstrong et al., 2003) showed
appears and is measured directly on the OPG film) that the diagnostic sensitivity for palatally placed canines was
is 1.15 times larger (i.e., 15% greater) than that of significantly greater using horizontal parallax (88%) com-
the adjacent central incisor (the canine-to-incisor pared to vertical parallax (69%). Hence, horizontal parallax is
250 IMPACTED CANINE

superior to vertical parallax in diagnostic accuracy. axis of the root of the central incisors.
Ericson and Kurol sectors’ classification as predictors of • Sector II lies distal to sector I and mesial to the long
severity of impacted canine axis of the root of the lateral incisors.
Dr Ericson and Dr Kurol (Ericson and Kurol, 1988b, Ericson • Sector III: lies distal to sector II and mesial to the
and Kurol, 1988a) were the first to provide a classification for long axis of the root of the first premolar
the position of the canine in both frontal and transverse sec-
It was found that sector 1 required approximately 6 more
tions, utilising both OPG and axial vertex views, to assess the
weeks of active orthodontic traction than sector 3 impaction.
severity of impaction.
Sector classification by Stivaros and Mandall
• Sector 1: Medial aspect of the impacted canine
crown in the primary canine region. These include :
• Sector 2: Medial aspect of impacted canine crown • Grade 1: No horizontal overlap of the canine crown
overlapping distal half of the lateral incisor root. with adjacent root. These canines have a good prog-
nosis of treatment, especially for interceptive ortho-
• Sector 3: Medial aspect of impacted canine crown
dontics.
overlapping mesial half of the lateral incisor root.
• Grade 2: Less than half of the root width of horizon-
• Sector 4: Medial aspect of impacted canine crown
tal overlap. Usually, canine horizontal overlap up to
overlapping distal half of the central incisor root.
half of the width with the adjacent root generally has
• Sector 5: Medial aspect of impacted canine crown an average prognosis for interceptive orthodontics.
overlapping mesial half of the central incisor root or
• Grade 3: More than half, but less than the whole root
greater.
width
Four sector classification by Lindauer (Lindauer et al.,
• Grade 4: complete overlap of root width or more.
1992)
This grade is usually considered too poor a progno-
These include: sis for interceptive orthodontics.
• Sector I: this represents the area distal to the line Alpha angle as predictors of severity of impacted canine
tangential to the distal heights of the lateral incisor
It is the angulation of the long axis of the canine to the upper
crown and root contour.
midline or midsagittal plane. It is graded as:
• Sector II: mesial to the sector I, but distal to the line
• Grade 1: 0–15° (good prognosis for interceptive or-
bisecting the lateral incisor’s long axis.
thodontics)
• Sector III: mesial to sector II, but distal to the mesial
• Grade 2: 16–30° (average prognosis for interceptive
heights of the contour of the lateral incisor crown
orthodontics)
and root.
• Grade 3: >31° (poor prognosis for interceptive or-
• Sector IV: all areas mesial to sector III.
thodontics)
based on Lindauer’s method, if the impacted canine
Impacted canine with an alpha angle above 55° is almost al-
passes the dental midline, it is termed transmigration.
ways considered extractions. According to Ericson (Ericson
Lindauer’s method reportedly identifies up to 78% of
and Kurol, 1988b), the risk of resorption of the root of the
the impacted canines in sectors II, III, and IV. (Lindau-
lateral incisor increases by 50% if the α angle is greater than
er et al., 1992). Dr Olive (Olive, 2005) used Lindauer’s
25°. Crescini (Crescini et al., 2007) found that an extra week
four sector classification and found that the severity of
of active orthodontic traction was required for every 5° of
impaction by sector was predictive of treatment dura-
α-angulation opening. According to a study by Stivaros and
tion. According to this study, canines in sectors II and III
Mandall (Stivaros and Mandall, 2000), orthodontists’ deci-
emerged after 8 months without any surgical interven-
sions to mechanically erupt or extract an impacted canine,
tion, while those impacted in sector IV emerged after 21
using radiographic information, depends upon labio-palatal
months of treatment.
crown position and angulation to the midline. According to
The three-sector classification by Dr Crescini (Crescini et Bonetti et al. (Alessandri Bonetti et al., 2009), the necessity of
al., 2007) treatment and the degree of treatment difficulty increases as
this angle increases.
These include:
β- and Gamma angle as predictors of severity of impacted
• Sector I lies between the dental midline and the long
canine
IMPACTED CANINE 251

β-angle is the angle between the long axis of the impacted Impaction of canine is associated with a 12% chance of lat-
maxillary canine and the long axis of the adjacent lateral eral incisors as estimated using plain radiographs (Ericson
incisor. According to Ericson (Ericson and Kurol, 1988b), and Kurol, 1987). CT (48%) and CBCT (66%) studies showed
the difficulty of impacted canine increases when the β angle a higher value of root resorption (Ericson and Kurol, 2000)
is more than 54°. According to Guarnieri (Guarnieri et al., (Walker et al., 2005).
2016), the β angle has the most significant influence on the
11% of the diagnoses based on OPG images were true posi-
prediction of root resorption. If the β angle is more than 54°,
tive, whereas the rest (89%) were false positive. Thus, root
the probability of having root resorption is greater than 61%.
contacts are overestimated when evaluated by OPG (Leuzing-
On the other hand, the Gamma angle measures the canine er et al., 2010). CBCT is more effective in evaluating the cases
angulation to the occlusal plane (Alqerban et al., 2016). that are difficult to diagnose in the initial evaluation using
conventional radiography. According to a systematic review
Distance of the canine’s crown from the occlusal plane as
(Eslami et al., 2017), there is no robust evidence to support
predictors of severity of impacted canine
the uses of CBCT as a first-line imaging method for impacted
The distance (d) represents the distance measured on OPG in maxillary canine evaluation. Still, it is indicated that 2D ra-
millimetres perpendicularly from the canine cusp tip to the diography does not provide sufficient information for clini-
occlusal plane. The severity of impaction, according to d, was cal decision-making, which might change the treatment plan
classified by Vermette (Vermette et al., 1995) into: (Alqerban et al., 2011).
• Mild impaction: distance of canine tip to the occlu- Early radiographic monitoring of patients with aberrant
sal plane is less than 12 mm. maxillary canine eruption is needed to detect resorption as
early as possible (Becker and Chaushu, 2005). Root resorp-
• Moderate impaction: distance of canine tip to the
tion rarely compromises the longevity of maxillary lateral
occlusal plane is between 12-15 mm
incisor (Parker, 1997) despite the increased mobility of teeth
• Severe impaction: distance of canine tip to the oc- with age (Jonsson et al., 2007).
clusal plane is greater than 15 mm.
Risk factors for resorption of lateral roots (Ericson and
Another grading for the vertical canine crown height was Kurol, 1988a)
provided by Stivaros and Mandall (Stivaros and Mandall,
These include:
2000). The crown of the impacted canine is graded relative to
the adjacent incisor. • Female to male (5:1 ratio)
• Grade 1: Below the level of the cementoenamel • Age less than 14 years: It has been stated that root
junction (CEJ). resorption of incisors by palatally ectopic canines
rarely starts after 14 years of age, and it occurs most
• Grade 2: Above the CEJ, but less than halfway up the
frequently between 11 and 12 years (Ericson and
root. (good prognosis for interceptive orthodontics)
Kurol, 1988a)
• Grade 3: More than halfway up the root, but less
• Horizontal impaction
than the full root length. (Average prognosis for in-
terceptive orthodontics) • Advanced canine root development
• Grade 4: Above the full length of the root. (Poor • Dental follicles are wider than 2 mm. However, it
prognosis for interceptive orthodontics) was found that the width of the dental follicle does
not correlate with the resorption (Ericson and Kurol,
Position of canine root apex anteroposteriorly as predic-
1988a, Brusveen et al., 2012).
tors of severity of impacted canine
• The pattern for root resorption associated with im-
The root apex of canine is graded into (Stivaros and Mandall,
pacted maxillary canines is mostly oblique rather
2000):
than horizontal (Chaushu et al., 2015).
• Grade 1: Above the region of the canine position
Management and treatment options for impacted canines
(good prognosis for interceptive orthodontics)
These include:
• Grade 2: Above the upper first premolar region (av-
erage prognosis for interceptive orthodontics) • No active treatment, only periodic radiographic
monitoring.
• Grade 3: Above the upper second premolar region
(poor prognosis for interceptive orthodontics) • Interceptive treatment by extraction of deciduous
canine.
Incidence of root resorption (RR)
252 IMPACTED CANINE

• Surgical exposure and orthodontic alignment. reported that deciduous canine extraction at the age of 10-
11 years resulted in 67% successful eruption of PDC. This
• Surgical removal of the permanent ectopic canine
improvement was shown to be 69% in PDC in another trial
with orthodontic space closure or prosthetic re-
(Naoumova et al., 2014). According to several trials published
placement.
by Naoumova and team (Naoumova et al., 2014, Naoumova
• Autotransplantation et al., 2015, Kjellberg et al., 2015, Naoumova and Kjellberg,
Indication for no active treatment 2018), extraction of deciduous canine is the most viable op-
tion for spontaneous correction of PDC.
Factors that determine when to consider this option are:
Guidelines for interceptive extraction of deciduous canine
• Satisfactory aesthetics
Ericson and Kurol (Ericson and Kurol, 1986a) suggested that
• Absence of root resorption of adjacent teeth/pathol- removing the deciduous canine before the age of 11 years will
ogy normalise the position of the ectopically erupting perma-
• Good contact between the lateral incisor and first nent canines in 91% of the cases if the canine crown is distal
premolar to the midline of the lateral incisor. On the other hand, the
success rate is only 64% if the canine crown is mesial to the
• Deciduous canine has a good prognosis midline of the lateral incisor. According to Naoumova’s trial
• Unfavourably impacted canine in sector 4 or 5 (Naoumova, 2014), the points that dictate successful inter-
ceptive treatment for PDCs were the distance of the canine
However, it is essential to biannually monitor the root resorp- cusp tip to occlusal plane and distance of the canine cusp
tion of the lateral incisor, cyst formation and transmigration tip-midline while patient age should be less than 11 years.
using radiographs (Ericson and Kurol, 1988a). There is no According to another trial by Naoumova & Kjellberg (Naou-
evidence currently available regarding the frequency of ra- mova and Kjellberg, 2018), PDC with an alpha angle less than
diographic review required in the long-term (Husain et al., 20 degrees and located in sector 2 can be observed without
2010). prior interceptive extraction. Interceptive extraction should
Interceptive treatment be done if PDC is located in sector 3 with an alpha angle be-
tween 20 and 30 degrees.
Interceptive treatment approaches are indicated in the late
mixed dentition, before CS4, and before the apex of the According to the Royal College of Surgeons of England
displaced canine is completely formed. If not intercepted guidelines on impacted canines (Husain et al., 2012), factors
with early treatment modalities, palatally displaced canines that determine whether to consider providing interceptive
(PDCs) progress into palatally impacted canines (PICs) in treatment by removal of the deciduous canine are as follows:
two out of three cases. • Age 10‑13 years,
Interceptive options are: • Absence of crowding.
a. Extraction of deciduous canine • The need to maintain space (or even create addi-
If PDC is present, deciduous canine extraction is usually rec- tional space) requires consideration. Space mainte-
ommended to create space or for the displaced canine. Ac- nance of primary canine (or even additional space
cording to systematic reviews (Almasoud, 2017, Alyammahi creation) requires careful assessment of the case.
et al., 2018), the eruption of PDCs can be facilitated by the • If radiographic examination reveals no improve-
extraction of primary canines. ment in the ectopic canine’s position 12 months after
According to Ericson (Ericson and Kurol, 1988a), after ex- extraction of the deciduous canine, alternative treat-
tracting deciduous canines, 78% of palatal canines show nor- ments should be considered.
malisation within 1 year (64% in 6 months) in uncrowded b. Other interceptive techniques for impacted or displayed
mouths. canine
Similar findings were reported by Power (Power and Short, A longitudinal study by Leonardi showed a 50% success rate
1993), where after extraction of canine, 62% PDC nor- with deciduous canine extraction versus an 80% rate when
malised, while 19% showed improvement. If PDC is present, headgear was combined with the deciduous canine extrac-
deciduous canine extraction should be performed as early as tion (Leonardi et al., 2010). A trial by Baccetti and colleagues
possible (Parkin et al., 2019). The recommended extraction reported 65.2%, 88% and 36% success rates with deciduous
age of deciduous canine is 10-13 years in uncrowded patients canine extraction, extraction along with cervical pull head-
(Parkin et al., 2012a). gear and control (no treatment) respectively (Baccetti et al.,
In a prospective RCT, Bazargani (Bazargani et al., 2013) 2008).
IMPACTED CANINE 253

Another trial by Baccetti and colleagues reported 80 % suc- • Easy visualisation enables reasonable control of
cess for the rapid maxillary expansion (RME)/transpalatal force vectors
arch (TPA)/extraction of primary canine (EC) therapy, 79%
• Immediate enucleation of the tooth follicle to mini-
for the TPA/EC therapy, 62.5% for the EC therapy and 28 %
mise the risk of root resorption of incisors if present.
in the control group (Baccetti et al., 2011). Another trial re-
ported 85.7% success when RME was combined with head- Disadvantages of open exposure
gear, while with headgear alone, the success rate was 82.3%.
These include:
The control showed a similar success rate of 36%. Deciduous
canine extraction was not undertaken in this RCT in either • Possibility of infection and inflammation due to its
group (Armi et al., 2011). invasiveness
Surgical exposure and orthodontic alignment • Open exposures cause discomfort (Björksved et al.,
2018). However, the RCT by Dr Parkin (Parkin et
The criteria for surgical exposure are:
al., 2012b) did not report a significant difference in
• If the canine fails to erupt within 12 months after in- patient discomfort between the open and closed sur-
terceptive treatment or interceptive treatment would gical techniques.
not give the desired results, surgical exposure and
• Some claimed that this technique is associated with
orthodontic alignment is indicated.
periodontal problems, gingival rescission and po-
• According to Parkin (Parkin et al., 2019), surgical tentially bone loss.
exposure should be done if the PDC is in medial sec-
• Re-exposure might be needed if there is inadequate
tors 3 and 4.
bone removal at the time of surgery, which will pre-
• According to the RCT of Naoumova (Naoumova vent autonomous eruption (Mathews and Kokich,
and Kjellberg, 2018), a PDC located in sector 4 with 2013).
an alpha angle >30 degrees should have immediate
• There are always chances (9.6%) of mucosa recover-
surgical exposure.
ing, especially for deeply placed canines (Parkin et
• According to another RCT by Naoumova, if the al., 2019). Naoumova (Naoumova et al., 2018) sug-
distance of the canine tip from the occlusal plane ex- gested glass ionomer cement as dressing to avoid
ceeds 5mm and from the midline, it exceeds 6 mm this issue, while Mathews and Kokich (Mathews and
with patient age greater than 11-12 years, surgical Kokich, 2013) advocated the use of light-cured peri-
exposure is desirable (Naoumova, 2014). odontal dressing (Barricaid™, Dentsply Sirona, PA,
USA).
Type of surgical exposure
• A common problem with open exposure is the
There are two types of surgical exposure for palatal and buc-
bunching of mucosa as the canine is pulled. This re-
cal impacted canines. Still, mainly, the surgical exposure is
sults in a shortening of the clinical crown and makes
usually dictated by the amount of keratinised tissue present
extrusion of the canine slow, thus increasing the
in the impacted area.
treatment time. In such cases, it is recommended to
Open exposure allow sufficient time for autonomous eruption be-
fore placing an appliance (Parkin et al., 2012b).
This is further subdivided into three subtypes, gingivectomy
(window or open exposure technique) and apical reposition- Closed surgical exposure
ing flap (Warford et al.)(Parkin et al., 2019). In the former
This technique involves the elevation of a mucoperiosteal flap,
technique, the canine is surgically exposed, a periodontal
removal of sufficient bone to allow exposure of the canine
dressing (COE-PAK™, GC Corporation, Tokyo, Japan) is
and its tooth movement, placement of attachment (usually
placed for 1 to 2 weeks (without sutures) on the exposed ca-
a bondable attachment with a gold chain), and reposition-
nine. After 7 days, the dressing is removed, and an attach-
ing the flap often through suturing. A minimum reasonable
ment is placed on the impacted canine; mechanical traction
amount of dental follicle should be removed to allow place-
is then initiated. Some clinicians prefer spontaneous autocor-
ment of attachment. In both open and closed surgical pro-
rection of impacted canine after removal of the dressing.
cedures, bone removal should not be done beyond the CEJ
Advantages of open exposure as it will increase the chances of ankylosis of the impacted
tooth. The close technique is preferred in high impacted ca-
These include:
nines, avoiding periodontal packing and open wounds. Trac-
• If the tooth is exposed correctly, there is lesser/no tion should be performed as early as possible (Becker and
need for re-exposure. Chaushu, 2005).
254 IMPACTED CANINE

Advantages of closed exposure modified and improved by Dr. Chris Chang (Zadeh, 2011).
Two parallel vertical incisions are made to expose and re-
These include:
move enough bone to create a tunnel for traction of the tooth.
(Parkin et al., 2019) If necessary, the bone covering the crown of the impacted ca-
nine is removed. A button is bonded to the buccal aspect of
• Minimal chance of infection compared to open ex-
the crown, and elastic chains are connected from the button
posure technique
to a stainless-steel TAD (2mm in diameter, 12mm in length)
• Less bone removal compared to open exposure inserted in the infra zygomatic crest (IZC). TAD location
technique ensures accurate orientation of the force system for optimal
• Rapid healing canine traction.
• Good aesthetic The surgical site is then closed with mono-nylon 6.0 sutures.
After the impacted canine is sufficiently exposed, the chain is
• No mucosal bunching removed, and orthodontic traction of the canine is initiated
Disadvantages of closed exposure (Bariani et al., 2017).
These include: It is claimed that the VISTA technique is more conservative

because it allows horizontal movement of the canine, posi-
• There may be some discomfort while applying trac- tioning it more favourably for traction without compromis-
tion forces post-surgically. ing the adjacent teeth (Zadeh, 2011). Space opening with
• As canine is not visualised, there is always difficult nickel-titanium coil springs before the initiation of traction
deciding the right direction of traction forces. from a low-intensity force (no more than 150g), as well as the
use of a second-generation elastic chain, can provide quick
• Chances of canine rotation if the attachment is and efficient mechanics for the eruption of a buccally impact-
placed on the palatal surface. Hence, correction of ed canine (Zadeh, 2011).
this rotation can increase the treatment time.
Choices of surgical exposure
• There would be even chances of pseudo-ankylosis
if the canine moved against the cortical bone. Even Both open and close surgical techniques are usually used for
true ankylosis can occur if prolonged forces are ap- palatal impacted canines. Apical repositioning flap is rarely
plied. used for palatal impacted canines as there is no deficiency of
keratinised gingiva on the palatal side. There is no reported
• Overeruption of canine can result from unsuper- difference in aesthetics, cost, periodontal health or patient
vised treatment mechanics. satisfaction between the two methods of exposure (Parkin
Crescini’s tunnel technique et al., 2015, Parkin et al., 2013). Similar findings were made
in Cochrane review (Parkin et al., 2017) with low quality of
This technique can be used for both palatal and buccal im- evidence. According to a systematic review of Sampaziotis
pacted canines (Crescini et al., 1994). In the “tunnel tech- (Sampaziotis et al., 2018), postoperative pain during the first
nique”, after the extraction of the primary canine, a muco- day is similar between the open and closed surgical exposure
periosteal flap is raised on the buccal or palatal aspect to patients. According to a systematic review of Cassina (Cas-
expose the cusp of the impacted tooth. The empty socket of sina et al., 2018), there were no significant differences in ad-
the primary tooth is extended to reach the impacted canine verse effects or patient-oriented outcomes between the two
cusp and form an osseous tunnel. A chain is passed through exposure techniques. Parkin (Parkin et al., 2019) stated that
the tunnel and fixed to a bonded device on the impacted cusp. an open surgical procedure is more beneficial as it helps make
The flap is sutured back into its original position. The chain the duration of treatment more predictable and decreases the
is used to traction the impacted canine toward the centre of time of active traction.
the alveolar ridge.
For Buccal impacted canine, both open and closed surgical
Evidence showed that no attachment loss and no recession procedures can be used depending upon the height of im-
were observed at the end of the active therapy (Crescini et pacted canines. Close surgical technique used mainly for
al., 1994) with no significant differences in keratinised tissue high impacted canines when the tooth is close to the centre of
width between test and control teeth at the follow-up exami- the alveolus and crown is apical to the mucogingival junction
nation (Crescini et al., 1994) (MGJ) (Kokich and Orthopedics, 2004). This technique pro-
Vestibular incision subperiosteal tunnel access (VISTA) tech- vides good aesthetic results for these high canines. Window
nique technique or gingivectomy is used when the canine crown
is not covered by a significant amount of bone and gingivae.
VISTA technique was introduced by Dr. Zadeh and later Also, an adequate amount of keratinised gingival should be
IMPACTED CANINE 255

present. This technique is feasible when after exposing one- • The K-9 spring (Park et al., 2004) is fabricated from
half to two-thirds of the crown, at least 3 mm of attached gin- 0.017” × 0.025” TMA wire and engaged in the buccal
giva should be present apical to the exposure; this technique segment.
though simple sacrifices, attached gingiva. Apical reposition-
• The monkey hook (Bowman and Carano, 2002):
ing Flap/ ARF (Warford et al.) is used when canine crown is
Monkey hook has an S-shaped design with an open-
apical to MGJ and less than 3 mm of attached gingival is pres-
loop at both ends.
ent. If the canine is overlapping lateral incisor than partial
thickness, ARF should be raised. • Cantilever system (Fischer et al., 2000)
Mechanical eruption of the impacted canine • Double-archwire mechanics using temporary an-
chorage devices (Kim and Gianelly, 2003)
Various techniques can be used for the mechanical eruption
of the impacted canine. These techniques apply an average • Auxiliary arm from transpalatal arch (Tausche and
force of 20 -70 grams during impacted canine traction (Rob- Harzer, 2008)
erts-Harry and Harradine, 1995, Sange and Thilander, 1990).
• Kilroy Spring- Kilroy II Spring (Bowman and Cara-
Usually, A TPA is used to maintain a transverse dimension,
no, 2003): They are used to apply vertical and lateral
but other mechanics can be used which do not put a strain on
eruptive forces. This spring is given with a fixed ap-
molars, such as:
pliance in place.
• Ballista spring (Jacoby, 1979): The ballista spring is
• Easy-Way-Coil (EWC) system (Schubert, 2008)
0.014, 0.016, or 0.018-inch round S/S wire, but TMA
wire can also be used. Indications for surgical removal of the palatally ectopic
permanent canine
• Attraction magnets: One magnet is bonded to ca-
nine while the other magnet can be a part of an up- These include:
per or lower removable appliance. However, there is • If the patient declines active treatment and/or is
toxicity risk due to corrosion, and the force increases happy with their dental appearance.
over time as the magnet follow inverse square law
with distance. • The case is not suitable for interceptive orthodon-
tics, and the patient is willing to wear fixed braces
• Stainless steel archwire auxiliary: Mostly used for bi- and have good motivation and oral health (Husain
lateral palatal impacted canine and made from 0.16 et al., 2012).
SS.
• If the canine has close proximity to the midline, has
• Cantilever spring or fishing rod: It is mainly made roots above the apices of neighbouring incisors, or
of 0.017” × 0.025” TMA wire. It can be used for both are horizontally impacted, they are unfavourable for
buccal and palatal impacted canines. orthodontic alignment, increasing age chances of
• TMA box loop: This is made from 0.017” × 0.025” orthodontic alignment decrease as there is increased
TMA wire. They are mostly used for buccal impact- risk of ankylosis of the canine(Husain et al., 2012).
ed canines. • It is usually required when the canine position of
• Removable appliances: Both upper and lower re- the impacted canine is unfavourable (sector 5 or in-
movable appliances can be used for traction of im- creased alpha angle or above the apices of the adja-
pacted canines. Traction can be done by elastics or cent teeth) (Parkin et al., 2019).
magnets. • Also, if the canine is rotated, ankylosed or associ-
• Two archwire techniques or Piggyback mechanics ated with some pathology, extraction of canine can
(Samuels and Rudge, 1997): In this technique, the be considered instead of extracting other teeth in the
main archwire and a lighter auxiliary wire are used arch.
to traction the impacted canine. The main archwire If the first premolar is considered as a replacement for perma-
is usually rectangular and made of stainless steel nent maxillary canine, then it is recommended to:
0.018-inch or 0.019*0.025-inch, while the lighter
wire is flexible 0.014-inch and made of nickel-titani- • Rotate the premolar mesiopalatally
um. • Apply buccal root torque to premolar
• Nickel-titanium closed-coil spring (Ross, 1999) • Intrude the premolar to match the gingival margins
• Mandibular or maxillary skeletal anchorage with an of the canine followed by occlusal buildup (Thomas
attached elastic or spring (Sinha and Nanda, 1999) Set al 1998).
256 IMPACTED CANINE

• Grind the palatal cusp of the first premolar • Resorption of the root of an adjacent tooth
• Aim for group function rather than canine guided • Availability of space
occlusion.
• Lack of compliance (e.g., missed appointments, in-
• Veneering the premolar adequate oral hygiene).
Indication of transalveolar autotransplant 2. Orthodontist-dependent factors such as:
These include: • Error in diagnosis in position of canine
• The interceptive option has failed, and the canine • Miss-diagnosis of resorption of the root of an adja-
is grossly malposition (Thomas Set al 1998, Moss, cent tooth
1975).
• Poor anchorage control
• When prolonged orthodontic treatment is unac-
• Inefficient biomechanics
ceptable to the patient.
3. Surgeon-dependent factors such as:
• Ideally, with the open apex at 13-14 years to aid in
maintaining vitality. The optimal development stage • Error in diagnosis
for autotransplantation is when the root is 50-75%
• Exposure on the wrong side, or rummaging expo-
formed (Kristerson, 1985).
sure
• There should be adequate space available for the
• Injury to the impacted tooth
canine and sufficient alveolar bone to accept the
transplanted tooth (Husain et al 2016, Husain et al., • Injury to the root of an adjacent tooth
2012). • Soft-tissue damage
a. The prognosis should be good for the canine tooth to • Surgery without orthodontic planning.
be transplanted with no evidence of ankylosis (Husain et al
2016, Husain et al., 2012). Impacted mandibular canine
Depending on the stage of root formation (that is, greater A systematic review (Dalessandri et al., 2017) found the in-
than 3/4 of the root formed), the transplanted canine may cidence of mandibular canine’s impaction ranges between
require root canal therapy to be commenced within 10 days 0.92 and 5.1%, while that of transmigration ranges from 0.1
following transplantation (Husain et al., 2012). to 0.31%.
Indication of surgical repositioning (McKay, 1978) Although the precise aetiology remains unknown, odon-
tomas (20%), cysts, and lateral incisor anomalies (16%) are
These include: more likely to play a role. The most common treatment strat-
• If the patient is unwilling for complex treatment egies are orthodontic traction for if the severity of impaction
is minor or surgical extraction if the impaction is severe. For
• Apex of the canine needs to be in a favourable posi-
transmigrant mandibular canines, if there are no hinders
tion
tooth movement, they can be left with radiographic moni-
• Extensive alveolar and palatal bone is removed, and toring; otherwise, they need to be extracted in most cases.
canine swung into place about fixed apex. According to a systematic review (Dalessandri et al., 2017),
surgical extraction for mandibular impacted canine was the
Causes of poor outcome
most favoured option (89 % ), while orthodontic traction is
These include: favored in 20-32 % of the cases with a 17 % failure rate.
1. Patient-dependent factors such as:
• Abnormal morphology of the impacted tooth and
root
• Dental health and periodontal status of dentition
(Woloshyn et al., 1994)
• Increased Age
• Pathology of the impacted tooth
• Unfavourably impacted tooth position
IMPACTED CANINE 257

Exam Night Review • Risk factors for resorption of lateral roots: (Ericson
and Kurol, 1988a)
Intraosseous position at CS5 or beyond, 2 or more years
after the adolescent growth spurt or 6M after completion. • Female, age less than 14 years
Prevalence and Incidence: • Horizontal palatal canines
Incidence of 1.7 to 2%, Palatal impaction 61% followed • Advanced canine root development
by the impaction within the line of the arch 34% while
• Canine crown medial to the midline of the lateral
buccal impaction only contributes 4.5%, Unilateral im-
incisor
pactions are 4 times. Female to male ratio 7:3
• Size of the follicle
Aetiology
Management and Treatment options
• Long tortuous path of eruption and developmental-
ly absent/ small lateral incisors (Brin et al., 1986b). • No active treatment/Leave and observe
• Deciduous canines are slightly resistant to resorp- • Interceptive treatment:
tion.
• Surgical Exposure and Orthodontic alignment
• Crowding leads to buccal impaction, while palatal
• Surgical removal of the palatally ectopic permanent
impactions are genetic.
canine:
Theories that explain the aetiology of palatally impacted
• Transalveolar transplant
canines:
• Surgical repositioning
• The guidance theory, as described by Becker et al. in
1981. Choices of surgical exposure
• The genetic theory, as defined by Peck et al. in 1994 For palatal impacted canines
Predictors of severity of impacted canine • Both open and closed surgical techniques are used.
Four sector classification of Lindauer (Lindauer et al., 1992) • There is no reported difference in aesthetics, cost,
include: periodontal health or patient satisfaction between
the two methods of exposure (Parkin et al., 2015,
• Sector I represents the area distal to the line tangen-
Parkin et al., 2013).
tial to the distal heights of the lateral incisor crown
and root contour. • Similar findings were made in Cochrane review
(Parkin et al., 2017) with low quality of evidence.
• Sector II: mesial to the sector I, but distal to the line
bisecting the lateral incisor’s long axis. For Buccal impacted canine
• Sector III: mesial to sector II, but distal to the mesial • For buccal impacted canines, both open and closed
heights of the contour of the lateral incisor crown surgical procedures can be used depending upon the
and root. height of impacted canines.
• Sector IV: all areas mesial to sector III. • Close surgical Technique: high impacted canines
when the tooth is close to the centre of alveolus, and
The three-sector classification by Dr Crescini (Crescini et
crown is apical to the mucogingival junction (MGJ)
al., 2007) are:
(Kokich and Orthopedics, 2004).
• Sector I lies between the dental midline and the long
Open Surgical technique (gingivectomy) This technique is
axis of the toot of the central incisors
used when the canine crown is not covered by a significant
• Sector II lies distal to sector I and mesial to the long amount of bone and is apical to MGJ.
axis of the root of the lateral incisors
• Sector III: lies distal to sector II and mesial to the
long axis of the toot of the first premolar
Root resorption of adjacent teeth
• 12% and 48% of lateral incisors as detected using
plain radiographs and CT scan, respectively
258 IMPACTED CANINE

References: BECKER, A., SMITH, P. & BEHAR, R. 1981. The incidence of
anomalous maxillary lateral incisors in relation to palatally-dis-
ALESSANDRI BONETTI, G., ZANARINI, M., DANESI, M.,
placed cuspids. Angle Orthod, 51, 24-9.
PARENTI, S. I. & GATTO, M. R. 2009. Percentiles relative to max-
illary permanent canine inclination by age: a radiologic study. Am J BISHARA, S. E. 1992. Impacted maxillary canines: a review. Am J
Orthod Dentofacial Orthop, 136, 486.e1-6; discussion 486-7. Orthod Dentofacial Orthop, 101, 159-71.
ALMASOUD, N. N. 2017. Extraction of primary canines for in- BJÖRKSVED, M., ARNRUP, K., LINDSTEN, R., MAGNUSSON,
terceptive orthodontic treatment of palatally displaced permanent A., SUNDELL, A. L., GUSTAFSSON, A. & BAZARGANI, F. 2018.
canines: A systematic review. Angle Orthod, 87, 878-885. Closed vs open surgical exposure of palatally displaced canines:
surgery time, postoperative complications, and patients’ percep-
ALQERBAN, A., JACOBS, R., FIEUWS, S. & WILLEMS, G. 2011.
tions: a multicentre, randomized, controlled trial. Eur J Orthod, 40,
Comparison of two cone beam computed tomographic systems
626-635.
versus panoramic imaging for localization of impacted maxillary
canines and detection of root resorption. Eur J Orthod, 33, 93-102. BOWMAN, S. J. & CARANO, A. 2002. The monkey hook: an
auxiliary for impacted, rotated, and displaced teeth. J Clin Orthod,
ALQERBAN, A., JACOBS, R., FIEUWS, S. & WILLEMS, G. 2016.
36, 375-8.
Predictors of root resorption associated with maxillary canine
impaction in panoramic images. Eur J Orthod, 38, 292-9. BOWMAN, S. J. & CARANO, A. 2003. The Kilroy Spring for im-
pacted teeth. J Clin Orthod, 37, 683-8.
ALYAMMAHI, A. S., KAKLAMANOS, E. G. & ATHANASIOU,
A. E. 2018. Effectiveness of extraction of primary canines for inter- BRIN, I., BECKER, A. & SHALHAV, M. 1986a. Position of the
ceptive management of palatally displaced permanent canines: a maxillary permanent canine in relation to anomalous or miss-
systematic review and meta-analysis. Eur J Orthod, 40, 149-156. ing lateral incisors: a population study. The European Journal of
Orthodontics, 8, 12-16.
ARMI, P., COZZA, P. & BACCETTI, T. 2011. Effect of RME and
headgear treatment on the eruption of palatally displaced canines: a BRIN, I., BECKER, A. & SHALHAV, M. 1986b. Position of the
randomized clinical study. Angle Orthod, 81, 370-4. maxillary permanent canine in relation to anomalous or missing
lateral incisors: a population study. Eur J Orthod, 8, 12-6.
ARMSTRONG, C., JOHNSTON, C., BURDEN, D. & STEVEN-
SON, M. 2003. Localizing ectopic maxillary canines--horizontal or BRUSVEEN, E. M., BRUDVIK, P., BOE, O. E. & MAVRAGANI,
vertical parallax? Eur J Orthod, 25, 585-9. M. 2012. Apical root resorption of incisors after orthodontic treat-
ment of impacted maxillary canines: a radiographic study. Am J
BACCETTI, T., LEONARDI, M. & ARMI, P. 2008. A randomized
clinical study of two interceptive approaches to palatally displaced
canines. Eur J Orthod, 30, 381-5. CASSINA, C., PAPAGEORGIOU, S. N. & ELIADES, T. 2018. Open
versus closed surgical exposure for permanent impacted canines: a
BACCETTI, T., SIGLER, L. M. & MCNAMARA, J. A., JR. 2011. An
systematic review and meta-analyses. Eur J Orthod, 40, 1-10.
RCT on treatment of palatally displaced canines with RME and/or
a transpalatal arch. Eur J Orthod, 33, 601-7. CHAUSHU, S., BECKER, A., ZELTSER, R., BRANSKI, S., VASK-
ER, N. & CHAUSHU, G. 2005. Patients perception of recovery after
BARIANI, R. C., MILANI, R., GUIMARAES JUNIOR, C. H.,
exposure of impacted teeth: a comparison of closed- versus open-
MOURA, W. S. & ORTOLANI, C. L. 2017. Orthodontic Traction
eruption techniques. J Oral Maxillofac Surg, 63, 323-9.
of Impacted Upper Canines Using the VISTA Technique. J Clin
Orthod, 51, 76-85. CHAUSHU, S., CHAUSHU, G. & BECKER, A. 1999. The use of
panoramic radiographs to localize displaced maxillary canines.
BAZARGANI, F., MAGNUSON, A. & LENNARTSSON, B. 2013.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 88, 511-6.
Effect of interceptive extraction of deciduous canine on palatally
displaced maxillary canine: a prospective randomized controlled CHAUSHU, S., KACZOR-URBANOWICZ, K., ZADURSKA, M. &
study. Angle Orthod, 84, 3-10. BECKER, A. 2015. Predisposing factors for severe incisor root re-
sorption associated with impacted maxillary canines. Am J Orthod
BECKER, A. 1978. The median diastema. Dent Clin North Am, 22,
685-710.
COUNIHAN, K., AL-AWADHI, E. A. & BUTLER, J. 2013. Guide-
BECKER, A. 2007. Orthodontic treatment of impacted teeth, CRC
lines for the assessment of the impacted maxillary canine. Dent
Press.
Update, 40, 770-2, 775-7.
BECKER, A. & CHAUSHU, S. 2000. Dental age in maxillary canine
CRESCINI, A., CLAUSER, C., GIORGETTI, R., CORTELLINI, P.
ectopia. Am J Orthod Dentofacial Orthop, 117, 657-62.
& PINI PRATO, G. P. 1994. Tunnel traction of infraosseous im-
BECKER, A. & CHAUSHU, S. 2005. Long-term follow-up of se- pacted maxillary canines. A three-year periodontal follow-up. Am J
verely resorbed maxillary incisors after resolution of an etiological- Orthod Dentofacial Orthop, 105, 61-72.
ly associated impacted canine. Am J Orthod Dentofacial Orthop,
CRESCINI, A., NIERI, M., BUTI, J., BACCETTI, T. & PINI PRA-
127, 650-4; quiz 754.
TO, G. P. 2007. Orthodontic and periodontal outcomes of treated
BECKER, A. & CHAUSHU, S. 2015. Etiology of maxillary canine impacted maxillary canines. Angle Orthod, 77, 571-7.
impaction: a review. Am J Orthod Dentofacial Orthop, 148, 557-67.
DACHI, S. F. & HOWELL, F. V. 1961. A survey of 3, 874 routine
IMPACTED CANINE 259

full-month radiographs. II. A study of impacted teeth. Oral Surg observations on aetiology, radiographic localization, prevention/
Oral Med Oral Pathol, 14, 1165-9. interception of impaction, and when to suspect impaction. Aust
Dent J, 41, 310-6.
DALESSANDRI, D., PARRINI, S., RUBIANO, R., GALLONE, D.
& MIGLIORATI, M. 2017. Impacted and transmigrant mandibular JACOBS, S. G. 1999. Radiographic localization of unerupted
canines incidence, aetiology, and treatment: a systematic review. maxillary anterior teeth using the vertical tube shift technique: the
Eur J Orthod, 39, 161-169. history and application of the method with some case reports. Am
ERICSON S & KUROL J 1987, R. A. O. E. M. C., AJODO, 91 ;483-
492. JACOBY, H. 1979. The ‘ballista spring” system for impacted teeth.
Am J Orthod, 75, 143-51.
ERICSON, S., BJERKLIN, K. & FALAHAT, B. 2002. Does the ca-
nine dental follicle cause resorption of permanent incisor roots? A JACOBY, H. 1983. The etiology of maxillary canine impactions.
computed tomographic study of erupting maxillary canines. Angle Am J Orthod, 84, 125-32.
Orthod, 72, 95-104.
JONSSON, A., MALMGREN, O. & LEVANDER, E. 2007. Long-
ERICSON, S. & KUROL, J. 1986a. Longitudinal study and analysis term follow-up of tooth mobility in maxillary incisors with
of clinical supervision of maxillary canine eruption. Community orthodontically induced apical root resorption. Eur J Orthod, 29,
Dent Oral Epidemiol, 14, 172-6. 482-7.
ERICSON, S. & KUROL, J. 1986b. Radiographic assessment of KAU, C. H., PAN, P., GALLERANO, R. L. & ENGLISH, J. D. 2009.
maxillary canine eruption in children with clinical signs of erup- A novel 3D classification system for canine impactions--the KPG
tion disturbance. Eur J Orthod, 8, 133-40. index. Int J Med Robot, 5, 291-6.
ERICSON, S. & KUROL, J. 1987. Radiographic examination of KETTLE, M. 1957. Treatment of the unerupted maxillary canine.
ectopically erupting maxillary canines. Am J Orthod Dentofacial Trans Br Soc Orthod, 32, 74-84.
Orthop, 91, 483-92.
KIM, E. & GIANELLY, A. A. 2003. Extraction vs nonextraction:
ERICSON, S. & KUROL, J. 1988a. Early treatment of palatally arch widths and smile esthetics. Angle Orthod, 73, 354-8.
erupting maxillary canines by extraction of the primary canines.
KJELLBERG, H., NAOUMOVA, J. & KÜROL, J. 2015. Extraction
of the deciduous canine as an interceptive treatment in children
ERICSON, S. & KUROL, J. 1988b. Resorption of maxillary lateral with palatally displaced canines—part II: possible predictors of
incisors caused by ectopic eruption of the canines. A clinical and success and cut-off points for a spontaneous eruption. European
radiographic analysis of predisposing factors. Am J Orthod Dento- Journal of Orthodontics, 37, 219-229.
KOKICH, V. G. J. A. J. O. O. & ORTHOPEDICS, D. 2004. Surgical
ERICSON, S. & KUROL, P. J. 2000. Resorption of incisors after and orthodontic management of impacted maxillary canines. 126,
ectopic eruption of maxillary canines: a CT study. Angle Orthod, 278-283.
70, 415-23.
KRISTERSON, L. J. I. J. O. O. S. 1985. Autotransplantation of hu-
FERGUSON, J. W. 1990. Management of the unerupted maxillary man premolars: a clinical and radiographic study of 100 teeth. 14,
canine. Br Dent J, 169, 11-7. 200-213.
FISCHER, T. J., ZIEGLER, F. & LUNDBERG, C. 2000. Cantilever LEONARDI, R., ANNUNZIATA, A., LICCIARDELLO, V. &
mechanics for treatment of impacted canines. J Clin Orthod, 34, BARBATO, E. 2010. Soft tissue changes following the extraction of
647-50. premolars in nongrowing patients with bimaxillary protrusion. A
systematic review. Angle Orthod, 80, 211-6.
FLEMING, P. S., SCOTT, P., HEIDARI, N. & DIBIASE, A. T. 2009.
Influence of radiographic position of ectopic canines on the dura- LEUZINGER, M., DUDIC, A., GIANNOPOULOU, C. & KILIARI-
tion of orthodontic treatment. Angle Orthod, 79, 442-6. DIS, S. 2010. Root-contact evaluation by panoramic radiography
and cone-beam computed tomography of super-high resolution.
GUARNIERI, R., CAVALLINI, C., VERNUCCI, R., VICHI, M.,
LEONARDI, R. & BARBATO, E. 2016. Impacted maxillary canines
and root resorption of adjacent teeth: A retrospective observational LINDAUER, S. J., RUBENSTEIN, L. K., HANG, W. M., ANDER-
study. Med Oral Patol Oral Cir Bucal, 21, e743-e750. SEN, W. C. & ISAACSON, R. J. 1992. Canine impaction identified
early with panoramic radiographs. J Am Dent Assoc, 123, 91-2,
HUSAIN ET AL 2016, M. O. T. P. E. M. C. R. C. O. S. O. E. G.,
95-7.
WWW.RCSENG.AC.UK/DENTAL.
LITSAS, G. & ACAR, A. 2011. A review of early displaced maxil-
HUSAIN, J., BURDEN, D. & MCSHERRY, P. 2010. Management of
lary canines: etiology, diagnosis and interceptive treatment. Open
the palatally ectopic maxillary canine.
Dent J, 5, 39-47.
HUSAIN, J., BURDEN, D., MCSHERRY, P., MORRIS, D. & AL-
LITTLEWOOD, S. J. & MITCHELL, L. 2019. An introduction to
LEN, M. 2012. National clinical guidelines for management of the
orthodontics, Oxford university press.
palatally ectopic maxillary canine. Br Dent J, 213, 171-6.
MATHEWS, D. P. & KOKICH, V. G. 2013. Palatally impacted
JACOBS, S. G. 1996. The impacted maxillary canine. Further
canines: the case for preorthodontic uncovering and autonomous
260 IMPACTED CANINE

eruption. Am J Orthod Dentofacial Orthop, 143, 450-8. Database Syst Rev, 3, Cd004621.
MCKAY, C. 1978. The unerupted maxillary canine. An assessment PARKIN, N. A., ALMUTAIRI, S. & BENSON, P. E. 2019. Surgical
of the role of surgery in 2,500 treated cases. Br Dent J, 145, 207-10. exposure and orthodontic alignment of palatally displaced canines:
can we shorten treatment time? J Orthod, 46, 54-59.
MITTAL, T. K., ATACK, N. E., NAISH, H. J., WILLIAMS, J. C.,
PURYER, J. S., SANDY, J. R. & IRELAND, A. J. J. O. U. 2017. The PARKIN, N. A., DEERY, C., SMITH, A. M., TINSLEY, D.,
aberrant canine part 1: aetiology and diagnosis. 10, 126-130. SANDLER, J. & BENSON, P. E. 2012b. No difference in surgical
outcomes between open and closed exposure of palatally displaced
MOSS, J. P. 1975. The indications for the transplantation of maxil-
maxillary canines. J Oral Maxillofac Surg, 70, 2026-34.
lary canines in the light of 100 cases. Br J Oral Surg, 12, 268-74.
PARKIN, N. A., FREEMAN, J. V., DEERY, C. & BENSON, P. E.
MOSSEY, P. A., CAMPBELL, H. M. & LUFFINGHAM, J. K. 1994.
2015. Esthetic judgments of palatally displaced canines 3 months
The palatal canine and the adjacent lateral incisor: a study of a west
postdebond after surgical exposure with either a closed or an open
of Scotland population. Br J Orthod, 21, 169-74.
technique. Am J Orthod Dentofacial Orthop, 147, 173-81.
NAGPAL, A., PAI, K. M., SETTY, S. & SHARMA, G. 2009. Local-
PARKIN, N. A., MILNER, R. S., DEERY, C., TINSLEY, D., SMITH,
ization of impacted maxillary canines using panoramic radiogra-
A. M., GERMAIN, P., FREEMAN, J. V., BELL, S. J. & BENSON, P.
phy. J Oral Sci, 51, 37-45.
E. 2013. Periodontal health of palatally displaced canines treated
NAOUMOVA, J. 2014. Interceptive Treatment Of Palatally Dis- with open or closed surgical technique: a multicenter, randomized
placed Canines. Swed Dent J Suppl, 7-118. controlled trial. Am J Orthod Dentofacial Orthop, 144, 176-84.
NAOUMOVA, J. & KJELLBERG, H. 2018. The use of panoramic POWER, S. M. & SHORT, M. B. 1993. An investigation into the
radiographs to decide when interceptive extraction is beneficial in response of palatally displaced canines to the removal of deciduous
children with palatally displaced canines based on a randomized canines and an assessment of factors contributing to favourable
clinical trial. Eur J Orthod, 40, 565-574. eruption. Br J Orthod, 20, 215-23.
NAOUMOVA, J., KUROL, J. & KJELLBERG, H. 2014. Extraction ROBERTS-HARRY, D. P. & HARRADINE, N. W. 1995. A sec-
of the deciduous canine as an interceptive treatment in children tional approach to the alignment of ectopic maxillary canines. Br J
with palatal displaced canines - part I: shall we extract the decidu- Orthod, 22, 67-70.
ous canine or not? Eur J Orthod, 37, 209-18.
ROSS, L. L. 1999. Technique Clinic-Nickel Titanium Closed-Coil
NAOUMOVA, J., KUROL, J. & KJELLBERG, H. 2015. Extraction Spring for Extrusion of Impacted Canines-A Jones Jig spring is
of the deciduous canine as an interceptive treatment in children used for de-impaction. Journal of Clinical Orthodontics, 33, 99-
with palatal displaced canines - part I: shall we extract the decidu- 100.
ous canine or not? Eur J Orthod, 37, 209-18.
SAMPAZIOTIS, D., TSOLAKIS, I. A., BITSANIS, E. & TSOLA-
NAOUMOVA, J., RAHBAR, E. & HANSEN, K. 2018. Glass-iono- KIS, A. I. 2018. Open versus closed surgical exposure of palatally
mer open exposure (GOPEX) versus closed exposure of palatally impacted maxillary canines: comparison of the different treatment
impacted canines: a retrospective study of treatment outcome and outcomes-a systematic review. Eur J Orthod, 40, 11-22.
orthodontists’ preferences. Eur J Orthod, 40, 617-625.
SAMUELS, R. H. & RUDGE, S. J. 1997. Two-archwire technique
OLIVE, R. J. 2005. Factors influencing the non-surgical eruption of for alignment of impacted teeth. J Clin Orthod, 31, 183-7.
palatally impacted canines. Aust Orthod J, 21, 95-101.
SANGE, S. & THILANDER, B. 1990. Transalveolar transplantation
PARK, H. S., KWON, O. W. & SUNG, J. H. 2004. Micro-implant of maxillary canines. A follow-up study. Eur J Orthod, 12, 140-7.
anchorage for forced eruption of impacted canines. J Clin Orthod,
SCHUBERT, M. 2008. A new technique for forced eruption of
38, 297-302.
impacted teeth. J Clin Orthod, 42, 175-9.
PARKER, W. S. 1997. Root resorption--long-term outcome. Am J
SINHA, P. K. & NANDA, R. S. 1999. Management of impacted
maxillary canines using mandibular anchorage. Am J Orthod Den-
PARKIN, N., BENSON, P. E., THIND, B., SHAH, A., KHALIL, I. tofacial Orthop, 115, 254-7.
& GHAFOOR, S. 2017. Open versus closed surgical exposure of
SOUTHALL, P. J. & GRAVELY, J. F. 1987. Radiographic localiza-
canine teeth that are displaced in the roof of the mouth. Cochrane
tion of unerupted teeth in the anterior part of the maxilla: a survey
Database Syst Rev, 8, Cd006966.
of methods currently employed. Br J Orthod, 14, 235-42.
PARKIN, N., FURNESS, S., SHAH, A., THIND, B., MARSHMAN,
STIVAROS, N. & MANDALL, N. A. 2000. Radiographic factors
Z., GLENROY, G., DYER, F. & BENSON, P. E. 2012a. Extraction
affecting the management of impacted upper permanent canines. J
of primary (baby) teeth for unerupted palatally displaced perma-
Orthod, 27, 169-73.
nent canine teeth in children. Cochrane Database Syst Rev, 12,
Cd004621. TAUSCHE, E. & HARZER, W. 2008. Treatment of a patient with
Class II malocclusion, impacted maxillary canine with a dilacerated
PARKIN, N., FURNESS, S., SHAH, A., THIND, B., MARSH-
root, and peg-shaped lateral incisors. Am J Orthod Dentofacial
MAN, Z., GLENROY, G., DYER, F. & BENSON, P. E. 2018.
Orthop, 133, 762-70.
WITHDRAWN: Extraction of primary (baby) teeth for unerupted
palatally displaced permanent canine teeth in children. Cochrane THOMAS SET AL 1998, A. O. T. I. T. A. R. B., 25;275-282.
IMPACTED CANINE 261

VERMETTE, M. E., KOKICH, V. G. & KENNEDY, D. B. 1995.
Uncovering labially impacted teeth: apically positioned flap and
closed-eruption techniques. Angle Orthod, 65, 23-32; discussion
33.
WALKER, L., ENCISO, R. & MAH, J. 2005. Three-dimensional
localization of maxillary canines with cone-beam computed to-
mography. Am J Orthod Dentofacial Orthop, 128, 418-23.
WARFORD, J. H., JR., GRANDHI, R. K. & TIRA, D. E. 2003.
Prediction of maxillary canine impaction using sectors and angular
measurement. Am J Orthod Dentofacial Orthop, 124, 651-5.
WEDL, J. S., SCHODER, V., BLAKE, F. A., SCHMELZLE, R. &
FRIEDRICH, R. E. 2004. Eruption times of permanent teeth in
teenage boys and girls in Izmir (Turkey). J Clin Forensic Med, 11,
299-302.
WOLOSHYN, H., ARTUN, J., KENNEDY, D. B. & JOONDEPH, D.
R. 1994. Pulpal and periodontal reactions to orthodontic alignment
of palatally impacted canines. Angle Orthod, 64, 257-64.
ZADEH, H. H. 2011. Minimally invasive treatment of maxillary
anterior gingival recession defects by vestibular incision subperi-
osteal tunnel access and platelet-derived growth factor BB. Int J
Periodontics Restorative Dent, 31, 653-60.
262 IMPACTED CANINE

Primary Failure Of
Eruptions
25
Written by: Mohammed Almuzian, Haris Khan, Ahmed El-Shanawany, Maha Urooj, Abbas Naseem
In this Chapter
1. Classification of failure of eruption
2. Incidence of PFE
3. Aetiology of PFE
4. Features of PFE
5. Treatment options of the PFE
6. Aetiology of the mechanical failure of eruption
P rimary failure of eruption (PFE) is defined as the failure of
• Positive family history of gene mutation. PFE is con-
sidered an idiopathic non-syndromic autosomal-
a permanent tooth to erupt in the absence of any mechanical dominant condition (Decker et al., 2008).
obstruction or systemic condition (OMIM 125350) (Proffit
and Vig, 1981). PFE is attributed to a disturbance in the erup- Features of PFE
tion mechanism, which results in complete failure of erup- These include:
tion (primary retention PFE) or partial failure of eruption
• Affected teeth are infra-occluded.
(secondary retention PFE) of a non-ankylosed tooth (Rhoads
et al., 2013). • Posterior open bite, however, average vertical pro-
portions.
Classification of failure of eruption
• Affected teeth are non-responsive to orthodontic
These include (Frazier-Bowers et al., 2007):
traction after slight movement; affected teeth be-
1. Primary failure of eruption which is subdivided into two come ankylosed.
types, depending on the clinical gradient of the open bite se-
• In PFE, the first permanent molars are constantly
verity:
involved with an increased second molar and second
• Type 1: Progressive anterior to posterior lateral open premolar involvement (Rhoads et al., 2013).
bite with lack of all involved teeth eruption poten-
• Teeth distally present to the affected tooth are usu-
tial. Type 1 appears to occur at a certain chronologi-
ally involved.
cal age.
• Affected teeth have a supracrestal presentation.
• Type 2: Teeth distal to the affected tooth have a
smaller lateral open bite but still inadequate erup- • Other dental anomalies can also be present.
tion. Type 2 correlates to the root developmental
• Radiographic features of ankylosis. It is essential to
stage.
notice that the sensitivity in diagnosing ankylosis
2. Secondary failure of eruption is an unexplained cessation is 60-70% with CBCT and 30-50% with OPG. This
in eruption after the tooth has penetrated the gingiva into the means that the chance of false-positive results with
oral cavity (Raghoebar et al., 1991a, Raghoebar et al., 1991b). OPG is almost 1 in 2 while 1 in 3 with the CBCT
(Ducommun et al., 2017).
3. Mechanical failure of eruption (Schätzle et al.) due to ob-
structed path of eruption with an apparent obstruction. Treatment options of the PFEc
4. Intermediate failure of eruption (IFE): Unclear if PFE or These include:
MFE due to the patient being too young to diagnose.
• No treatment for mild cases
Incidence of PFE
• Segmental osteotomy includes corticotomy and seg-
In summary: ment distraction to extrude the affected tooth and
alveolar bone to erupt. Some recommend using an
• The incidence of PFE is 0.6% (Frazier-Bowers et al.,
orthodontic bone stretching (Bousquet et al., 2016).
2016).
• Restoration of the occlusal table: This may involve
• Familial predilection in PFE is found in 10% - 40%
composite build-ups, prosthetic crowns, bridgework
of cases with females and permanent molars most
or extraction and implants placement. Restoration of
affected (Rhoads et al., 2013, Ahmad et al., 2006).
occlusion need a multi-disciplinary approach, and a
• PFE is usually found in Class 3 malocclusion cases. definite treatment plan is based on several erupted
• There is no difference between maxillary and man- teeth and the vertical functional occlusal height to
dibular involvement for PFE. be restored (Rhoads et al., 2013).
•
PFE mainly occur bilaterally, affecting multiple Aetiology of the mechanical failure of eruption
teeth. These include:
Aetiology of PFE 1. Local factors due to mucosal barrier such as supernumer-
These include: ary or arch length deficiency as well as severe trauma
• Mutation in parathyroid hormone receptor 1 gene 2. Systemic factors

(PTH1R, 168468.0012) has been reported as the • Genetic disorders
main etiological of PFE (Frazier-Bowers et al., 2010).
264 PRIMARY FAILURE OF ERUPTION

• Cleft lip/ palate • Teeth distal to the affected tooth are usually in-
volved.
• Cleidocranial dysostosis
• Affected teeth have a supracrestal presentation.
• Osteoporosis
• Other dental anomalies may also be present.
• Gardner’s syndrome
Treatment options of the PFE
• Endocrinal disorders (Hypopituitarism, Hypothy-
roidism and Hypoparathyroidism) 1. No treatment,
3. Environmental factors such as radiation, nutritional defi- 2. Limited orthodontic treatment:
ciency or drugs therapy like phenytoin
3. Segmental osteotomy.
4. Idiopathic factors (PFE, MFE and IFE).
4. Restoration of the occlusal table.
Exam night review

Primary failure of eruption (PFE) is defined as the failure of
a permanent tooth to erupt in the absence of any mechanical
obstruction or systemic condition (OMIM 125350) (Proffit
and Vig, 1981).
Classification of failure of eruption Frazier-Bowers 2007
(Frazier-Bowers et al., 2007)
• Primary failure of eruption
• Secondary failure of eruption
• Mechanical failure of eruption (Schätzle et al.)
• Intermediate failure of eruption (IFE)
Incidence
• The incidence of PFE is 0.6% (Frazier-Bowers et al.,
2016).
• Familial predilection in PFE is found in 10% - 40%
of cases, primarily females and permanent molars
affected (Rhoads et al., 2013, Ahmad et al., 2006).
• PFE is usually found with class 3 malocclusion.
• No difference b/t maxillary and mandibular involve-
ment.
• Bilateral occurrence affecting multiple teeth.
Features of PFE
• Affected teeth are infra-occluded.
• Posterior openbite.
• Non-responsive to orthodontic traction.
• First permanent molars are constantly involved with
increased frequency of second molar and second
premolar involvement (Rhoads et al., 2013).
PRIMARY FAILURE OF ERUPTION 265

References
AHMAD, S., BISTER, D. & COBOURNE, M. T. 2006. The clinical
features and aetiological basis of primary eruption failure. The Eu-
ropean Journal of Orthodontics, 28, 535-540.
BOUSQUET, P., ARTZ, C., RENAUD, M. & CANAL, P. 2016. Re-
location of Infrapositioned Ankylosed Teeth: Description of Orth-
odontic Bone Stretching and Case Series. Journal of Oral and Maxil-
lofacial Surgery, 74, 1914-1925.
DECKER, E., STELLZIG-EISENHAUER, A., FIEBIG, B. S., RAU,
C., KRESS, W., SAAR, K., RÜSCHENDORF, F., HUBNER, N.,
GRIMM, T. & WEBER, B. H. 2008. PTHR1 loss-of-function muta-
tions in familial, nonsyndromic primary failure of tooth eruption.
Am J Hum Genet, 83, 781-6.
DUCOMMUN, F., BORNSTEIN, M. M., BOSSHARDT, D., KAT-
SAROS, C. & DULA, K. 2017. Diagnosis of tooth ankylosis using
panoramic views, cone beam computed tomography, and histologi-
cal data: a retrospective observational case series study. European
Journal of Orthodontics, 40, 231-238.
DUNBAR, C. & SLATTERY, D. 2015. Failure of eruption of poste-
rior teeth. Orthodontic Update, 8, 63-68.
FRAZIER-BOWERS, S. A., KOEHLER, K. E., ACKERMAN, J. L. &
PROFFIT, W. R. 2007. Primary failure of eruption: further charac-
terization of a rare eruption disorder. American Journal of Ortho-
dontics and Dentofacial Orthopedics, 131, 578. e1-578. e11.
FRAZIER-BOWERS, S. A., LONG, S. & TUCKER, M. Primary fail-
ure of eruption and other eruption disorders—Considerations for
management by the orthodontist and oral surgeon. Seminars in Or-
thodontics, 2016. Elsevier, 34-44.
FRAZIER-BOWERS, S. A., SIMMONS, D., WRIGHT, J. T., PROF-
FIT, W. R. & ACKERMAN, J. L. 2010. Primary failure of eruption
and PTH1R: the importance of a genetic diagnosis for orthodontic
treatment planning. American Journal of Orthodontics and Dento-
facial Orthopedics, 137, 160. e1-160. e7.
HANISCH, M., HANISCH, L., KLEINHEINZ, J. & JUNG, S. 2018.
Primary failure of eruption (PFE): a systematic review. Head Face
Med, 14, 5.
PROFFIT, W. R. & VIG, K. W. 1981. Primary failure of eruption: a
possible cause of posterior open-bite. Am J Orthod, 80, 173-90.
RAGHOEBAR, G., BOERING, G. & VISSINK, A. 1991a. Clinical,
radiographic and histological characteristics of secondary retention
of permanent molars. Journal of dentistry, 19, 164-170.
RAGHOEBAR, G., BOERING, G., VISSINK, A. & STEGENGA, B.
1991b. Eruption disturbances of permanent molars: a review. Jour-
nal of oral pathology & medicine, 20, 159-66.
RHOADS, S. G., HENDRICKS, H. M. & FRAZIER-BOWERS, S.
A. 2013. Establishing the diagnostic criteria for eruption disorders
based on genetic and clinical data. American Journal of Orthodon-
tics and Dentofacial Orthopedics, 144, 194-202.
SCHÄTZLE, M., IMFELD, T., SENER, B. & SCHMIDLIN, P. R.
2008. In vitro tooth cleaning efficacy of manual toothbrushes around
brackets. The European Journal of Orthodontics, 31, 103-107.
266 PRIMARY FAILURE OF ERUPTION

Transposition of teeth
26
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Muhammad Qasim Saeed
In this Chapter
1. Types of transposition
2. Aetiology of transposition
3. Prevalence of transposition
4. Classification of transposition
5. Treatment planning consideration
6. Maxillary canine and the first premolar
7. Maxillary canine-lateral incisor transposition
8. Maxillary canine-first molar transposition
9. Maxillary incisors transposition
10. Maxillary canine central incisor transposition
11. Mandibular canine lateral incisor transposition
12. Mandibular canine central incisor transposition
13. Intraosseous migration
14. Clinical signs of intraosseous migration
15. Classification of intraosseous migration
T ooth transposition is the positional interchange of two
the upper arch (Peck and Peck, 1995) are:
• Canine–first premolar (Mx.C.P1).
adjacent teeth or the eruption of a tooth in a position usu-
ally occupied by a nonadjacent tooth. Transposition is also • Canine–lateral incisor (Mx.C.I2).
known as ‘Transversion’ (Lischer, 1912).
• Canine on the site of first molar (Mx.C.M1).
Types of transposition
• Lateral incisor–central incisor (Mx.I2.I1).
These include:
• Canine on the site of the central incisor (Mx.IC.I1).
• Complete transposition or true transposition in
While the commonest types of transposition which are found
which both the crown and roots of adjacent teeth
in the lower arch are (Aydin et al., 2004):
are completely transposed (Shapira and Kuftinec,
1989b). • Mandibular lateral incisor-canine transposition (Mn.
I2.C).
• Incomplete or pseudo-or partial transposition in-
volves interchange in the positions of adjacent • Mandibular canine transmigrated/erupted (Mn.C. tran-
crowns only, with the roots remaining in their cor- serupted).
rect position (Shapira and Kuftinec, 1989b).
Maxillary canine and the first premolar (Mx.C.P1) (Pair,
Aetiology of transposition 2011, Peck et al., 1993)
These include: The overall prevalence of Mx.C.P1 is 55%-70%. Bilateral oc-
currence occur in 27% of the cases. The familial occurrence is
•
Multifactorial, both genetic and environmental
11% while the male to female ratio is 1:1.55. The clinical signs
components are involved (Shapira and Kuftinec,
of of Mx.C.P1 (Filhoa et al., 2007) are:
1989b, Peck et al., 1993).
• Canine is usually displaced between the first and
• Strong association with tooth agenesis and peg-
second premolars in a mesiobuccal direction.
shaped upper lateral incisor teeth.
• First premolar is frequently distally tipped and dis-
Prevalence of transposition
placed in a mesio-palatal direction.
According to a meta-analysis, the overall prevalence of trans-
• The primary canine is often present, creating local-
position is 0.33% (Papadopoulos et al., 2010). transposition
ised crowding.
mostly affecting upper teeth, 68.5%-76% (Papadopoulos et
al., 2010). Canines are involved in 90% of transposition cases Treatment options of of Mx.C.P1 are:
(Ely et al., 2006b), mostly (88%) unilateral (Ely et al., 2006a).
1. Interceptive treatment (Peck and Peck, 1995): This in-
There is left-sided dominance of transposition though trans-
volves the extraction of the retained primary tooth between
position has never been reported in both arches simultane-
six and eight years of age. Interceptive treatment can be ad-
ously (Shapira and Kuftinec, 1989a) or in deciduous dentition.
opted before transposition is complete, usually around 10
Some studies reported female predilection of transposition
years of age.
though a meta-analysis reported no specific gender predilec-
tion (Papadopoulos et al., 2010). 2. Definitive treatment such as (Shapira and Kuftinec,
1989a):
Classification
• Accepting the transposition.
Three-part coding was purposed to classify transpositions
(Favot et al., 1986, Peck and Peck, 1995) including: • Extraction of one of the transposed teeth followed
by orthodontic alignment after opting for either ac-
• Part 1: Jaw of occurrence, coded as either Mx = Maxilla
cepting or correcting the transposition (Filhoa et al.,
or Mn = Mandible.
2007).
• Part 2: Transposed tooth, coded as - I1 = central incisor,
• Correcting the transposition: When repositioning
I2 = lateral incisor, C = canine, P1 = first premolar, P2 =
the transposed teeth, care should be taken to avoid
second premolar, M1 = first molar, M2 = second molar.
occlusal interference and root resorption, as well as
• Part 3: Site of transposition, same coding as part 2. bone loss of the buccal bone plate. The palatally dis-
placed premolar should be initially moved palatally
Example: Mx.C.P1 represents transposition of the maxillary
‘palatal parking’ to allow unrestricted buccal move-
canine to the first premolar position.
ment of the canine toward its normal position. Af-
The five common types of transpositions which are found in ter repositioning the canine, the premolar may be
268 TRANSPOSITION OF TEETH

moved back to its normal bucco-palatal work. It is a rare type of transpositions (2% of maxillary canine
transpositions) (Ali et al., 2014). Mx.C.I1 develops secondary
Factors affecting treatment decision
to early loss of central incisor (trauma/caries).
These include:
Mandibular canine lateral incisor transposition (Mn.I2.C)
• Facial aesthetics.
It has a significant association with other dental anomalies
• Duration of orthodontic treatment. cited as evidence for genetic control (Peck et al., 1998).
• Patient socioeconomic status. Mn.I2.C is frequently pseudo-transposed (Brezniak et al.,
1993) and usually associated with peg laterals, hypodontia
• Risk of caries.
and bilateral occurrence.
• Root and crown position as they are related to the
Treatment options of Mn.I2.C are:
risk of root resorption.
• Extraction of primary teeth.
• Gingival quality and gingival level of the transposed
teeth. • Accept transposition.
• Dental morphology and the need for dental reshap- • Extraction of lateral incisor if crowding is present.
ing.
• Restorative camouflage.
• Occlusal and dental crowding.
Mandibular canine central incisor transposition (Mn.C.I1)
Maxillary canine-lateral incisor transposition (Mx.C. I2)
It is a rare type of transposition with uncertain aetiology.
(Pair, 2011)
Treatment involves removal of the primary tooth, accept
Prevalence of Mx.C. I2: Overall, it ranges from 20%-42%. Bi- transposition or de-rotation of the transposed canine and
lateral occurrence is 5%. Pseudo-transposition of this type is periodontal surgery.
more common than true transposition.
Intraosseous migration
Aetiology of of Mx.C. I2: It is usually due to trauma in the
Ando was the first to use the term transmigration (ANDO et
primary dentition and subsequent permanent tooth drift. A
al., 1964) and defined it as intraosseous migration of a tooth
genetic basis for some occurrences cannot be excluded but
crossing the midline. Transmigration of unerupted teeth is a
is rare (Maia, 2000). Mx.C.I2 is associated with incisor root
rare phenomenon and occurs more commonly in the lower
dysmorphism (Ghosh, 2018).
jaw (Tarsitano et al., 1971). Transmigration in the upper arch
Treatment options of of Mx.C. I2 (Lorente et al., 2016) in- is considered extremely rare and reported in the form of a few
clude: case reports (Shapira and Kuftinec, 2005, Mittal et al., 2017).
• Interceptive treatment: Extraction retained primary The teeth most commonly involved are canines and second
tooth. premolars—the incidence of Mn. C. transerupted is 0.02%
(Peck et al., 1998).
• Definitive treatment: Accept transposition if com-
plete; correction may involve iatrogenic loss of buc- Aetiology of intraosseous migration (Shapira and Kuft-
cal periodontal attachment of the canine, leading to inec, 2005)
a long clinical crown.
A genetic aetiology is usually cited for this type of transpo-
Maxillary canine-first molar transposition (Mx.C.M1) sition. Other factors cited to contribute to transmigration
are: Trauma, cyst, premature loss of canine, hypodontia,
The aetiology of Mx.C.M1 is a rare event usually associat-
proclination of the lower incisors, increased axial inclination
ed with the early loss of first or second primary molars. The
of the unerupted canine more than 50 degrees an enlarged
clinical sign of of Mx.C.M1 is that the upper canine erupts in
symphyseal cross-sectional area of the chin.
the first permanent molar space, with a mesiopalatal rotation
and palatal displacement. Treatment option of of Mx.C.M1 is Clinical signs of intraosseous migration
usually accepting the transposition.
These include:
Maxillary incisors transposition (Mx.I2.I1)
• Absence of mandibular canines in the dental arch.
It is usually due to early life trauma in the incisor region.
• Delayed retention of the mandibular primary ca-
Treatment option is accepting the transpositions, with re-
nine.
storative camouflage treatment.
• Treatment is primarily surgical extraction of the
Maxillary canine central incisor transposition (Mx.C.I1)
transmigrated canine.
TRANSPOSITION OF TEETH 269

Mupparapu classification for transmigrated mandibular et al., 2006b)
canine (Mupparapu, 2002)
• Mostly unilateral, 88% (Ely et al., 2006a).
These include:
• Left-sided dominance.
• Type 1: Canine positioned mesioangular across the
Classification
midline within the jaw bone, labial or lingual to an-
terior teeth, and the crown crossing the midline. • Three-part coding was purposed to classify transpo-
sitions (Favot et al., 1986, Peck and Peck, 1995):
• Type 2: Canine horizontally impacted near the in-
ferior border of the mandible, below the incisor api- Part 1: Jaw of occurrence
ces.
Part 2: Transposed tooth
• Type 3: Canine erupting either mesial or distal to the
Part 3: Site of transposition
opposite canine.
Maxilla / upper arch: In order of most frequent to less
• Type 4: Canine horizontally impacted near the in-
frequent (Peck and Peck, 1995).
ferior border of the mandible, below the apices of
either premolars or molars on the opposite side. • (Mx.C.P1).
• Type 5: Canine positioned vertically in the midline • (Mx.C.I2).
(the long axis of the tooth crossing the midline) ir- • (Mx.C.M1).
respective of eruption status.
• (Mx.I2.I1).
Exam night review • (Mx.IC.I1).
Definition Maxillary canine and the first premolar (Mx.C.P1) (Pair,

2011, Peck et al., 1993)
• Tooth transposition / Transversion is the positional
interchange of two adjacent teeth or the eruption of Prevalence
a tooth in a position usually occupied by a nonadja- • Overall 55%-70%.
cent tooth.
• Bilateral occurrence 27%.
• Types of transposition Complete transposition/
Clinical signs (Filhoa et al., 2007)
true transposition: Crown and roots of adjacent
teeth are completely transposed • Canine is usually displaced between the first and
second premolars in a mesiobuccal direction.
• Incomplete or pseudo-or partial transposition: In-
terchange in the positions of adjacent crowns. • First premolar is frequently distally tipped and dis-
placed in a mesio-palatal direction.
Aetiology
• The primary canine is often present, creating local-
• Unclear.
ised crowding.
•
Multifactorial, both genetic and environmental
Maxillary canine-lateral incisor transposition (Mx.C. I2)
components are involved (Shapira and Kuftinec,
(Pair, 2011)
1989b, Peck et al., 1993).
Prevalence
• Female predilection (controversial).
• 20%-42%.
• Tooth agenesis.
• Bilateral occurrence: 5%.
• Peg-shaped upper lateral incisor teeth.
Prevalence
Aetiology
• According to a meta-analysis, the overall preva-
lence of transposition is 0.33% (Papadopoulos et al., • It is usually due to trauma in the primary dentition
2010). and subsequent permanent tooth drift. A genetic ba-
sis for some occurrences cannot be excluded but is
• It mainly affects upper teeth, 68.5%-76% (Papado-
rare (Maia, 2000).
poulos et al., 2010).
• Mx.C.I2 is associated with incisor root dysmor-
• Canines are involved in 90% of transpositions (Ely
phism (Ghosh, 2018).

Maxillary canine-first molar transposition (Mx.C.M1) References
Aetiology ALI, Z., JAISINGHANI, A. C., WARING, D. & MALIK, O. 2014.

Transposition of maxillary canine to central incisor site: aetiology,
• It is a rare event, usually associated with the early treatment options and case report. Journal of orthodontics, 41,
loss of first or second primary molars. 233-244.
Clinical signs ANDO, S., AIZAWA, K., NAKASHIMA, T., SANKA, Y., SHIMBO,
K. & KIYOKAWA, K. 1964. Transmigration process of the im-
• Upper canine erupts in the first permanent molar pacted mandibular cuspid. The Journal of Nihon University School
space, with a mesiopalatal rotation and palatal dis- of Dentistry, 6, 66-71.
placement.
AYDIN, U., YILMAZ, H. H. & YILDIRIM, D. 2004. Incidence
• Treatment options of canine impaction and transmigration in a patient population.
Dentomaxillofac Radiol, 33, 164-9.
• Accept transposition.
BREZNIAK, N., BEN-YEHUDA, A. & SHAPIRA, Y. 1993. Unusual
intraosseous migration mandibular canine transposition: a case report. American Journal
• Transmigration is defined as the intraosseous mi- of Orthodontics and Dentofacial Orthopedics, 104, 91-94.
gration of a tooth crossing the midline. DE GRAUWE, A., AYAZ, I., SHUJAAT, S., DIMITROV, S., GBA-
DEGBEGNON, L., VANDE VANNET, B. & JACOBS, R. 2019.
Prevalence CBCT in orthodontics: a systematic review on justification of
• Mn. C. transerupted is 0.02% (Peck et al., 1998), a CBCT in a paediatric population prior to orthodontic treatment.
rare phenomenon and occurs more commonly in Eur J Orthod, 41, 381-389.
the lower jaw (Tarsitano et al., 1971). ELY, N. J., SHERRIFF, M. & COBOURNE, M. T. 2006a. Dental
transposition as a disorder of genetic origin. Eur J Orthod, 28,
145-51.
ELY, N. J., SHERRIFF, M. & COBOURNE, M. T. 2006b. Dental
transposition as a disorder of genetic origin. The European Journal
FILHOA, L. C., DE ALMEIDA CARDOSOB, M., ANC, T. L. &
BERTOZD, F. A. 2007. Maxillary Canine—First Premolar Transpo-
sition. Angle Orthodontist, 77, 167.
GHOSH, A. 2018. Orthodontic management of maxillary canine
and lateral incisor pseudo-transposition: A 4-year follow-up. Jour-
nal of Indian Orthodontic Society, 52, 137.
LISCHER, B. E. 1912. Principles and methods of orthodontics:
An introductory study of the art for students and practitioners of
dentistry, Lea & Febiger.
LORENTE, T., LORENTE, C., MURRAY, P. G. & LORENTE, P.
2016. Surgical and orthodontic management of maxillary canine-
lateral incisor transpositions. Am J Orthod Dentofacial Orthop,
150, 876-885.
MITTAL, T. K., ATACK, N. E., WILLIAMS, J. C., PURYER, J. S.,
SANDY, J. R. & IRELAND, A. J. 2017. The aberrant second premo-
lar. Orthodontic Update, 10, 96-101.
MUPPARAPU, M. 2002. Patterns of intra-osseous transmigration
and ectopic eruption of mandibular canines: review of literature
and report of nine additional cases. Dentomaxillofacial Radiology,
31, 355-360.
PAIR, J. 2011. Transposition of a maxillary canine and a lateral
incisor and use of cone-beam computed tomography for treat-
ment planning. American Journal of Orthodontics and Dentofacial
PAPADOPOULOS, M. A., CHATZOUDI, M. & KAKLAMANOS,
E. G. 2010. Prevalence of tooth transposition: a meta-analysis. The
TRANSPOSITION OF TEETH 271

PAPADOPOULOS, M. A., CHATZOUDI, M. & KARAGIANNIS,
V. 2009. Assessment of characteristic features and dental anomalies
accompanying tooth transposition: a meta-analysis. Am J Orthod
Dentofacial Orthop, 136, 308.e1-10; discussion 308-9.
PECK, L., PECK, S. & ATTIA, Y. 1993. Maxillary canine-first pre-
molar transposition, associated dental anomalies and genetic basis.
The Angle Orthodontist, 63, 99-109.
PECK, S. & PECK, L. 1995. Classification of maxillary tooth trans-
positions. Am J Orthod Dentofacial Orthop, 107, 505-17.
PECK, S., PECK, L. & KATAJA, M. 1998. Mandibular lateral
incisor-canine transposition, concomitant dental anomalies, and
genetic control. Angle Orthod, 68, 455-66.
SHAPIRA, Y. & KUFTINEC, M. M. 1989a. Maxillary canine-lateral
incisor transposition—orthodontic management. American Jour-
nal of Orthodontics and Dentofacial Orthopedics, 95, 439-444.
SHAPIRA, Y. & KUFTINEC, M. M. 1989b. Tooth transpositions-
-a review of the literature and treatment considerations. Angle
Orthod, 59, 271-6.
SHAPIRA, Y. & KUFTINEC, M. M. 2005. Unusual intraosseous
transmigration of a palatally impacted canine. American journal of
orthodontics and dentofacial orthopedics, 127, 360-363.
TARSITANO, J. J., WOOTEN, J. W. & BURDITT, J. T. 1971. Trans-
migration of nonerupted mandibular canines: report of cases. The
Journal of the American Dental Association, 82, 1395-1397.

Third molar and its
27
impaction
Written by: Mohammed Almuzian, Haris Khan, Muhammad Qasim Saeed
In this Chapter
1. Prevalence of third molar impaction and hy
podontia
2. Aetiology of third molar impaction
3. Classification of third molar impaction
4. Lower incisor crowding and third molar debate
5. Research recommendations
T ooth impaction is a tooth whose root is developed more
ond molar’s cervical margin.
C. According to the inclination of the long axis of the third
than three-quarters of the final root length and whose spon-
taneous eruption is not expected in a reasonable time in its molar about the long axis of the second molar
normal functional position due to the bone, tooth, or fibrous • Vertical Impaction
tissue considered to be an impacted tooth.
• Horizontal impaction
Prevalence of third molar impaction and hypodontia
• Mesio-angular impaction
Third molars hypodontia are common among more females;
• Disto-angular impaction
the females to males ratio are 3:2 (Richardson, 1979). Third
molars impaction is the most among all the teeth. An inci- • Inverted impaction
dence of 16.7% to 68.6%% has been reported in the literature
Lower incisor crowding and third molar debate
(Hashemipour et al., 2013; Bishara and Andreasen, 1983).
Studies relating third molars impaction to lower incisors
Aetiology of third molar impaction
crowding. Bergstrom and Jensen’s study (Bergstrom, 1960)
These include: found a greater degree of crowding in both maxilla and
mandible on the side where the third molar was present.
• Systemic causes include endocranial dysfunction,
Richardson and Mills(Richardson and Mills, 1990) sug-
developmental diseases and genetic disorders such
gested that the presence of a developing third molar can, in
as cleidocranial dysostosis and cleft lip/ palate.
some cases, cause forward movement of buccal teeth with an
• Local causes such as lack of space due to macordon- increase in crowding. They proposed that the second molar
tia or under-development mandible (micrognathia), extraction effectively reduces the incidence of late lower arch
the excessive density of the bone or the soft tissues crowding.
overlying the tooth and ectopic position of the third
Studies refute the relationship between third molars impac-
molars.
tion and lower incisors crowding. Ades and Harradine (Ades
Classification of third molar impaction et al., 1990; Harradine et al., 1998) found a lack of corre-
These include: lation between third molars and crowding. In their ran-
domised clinical trial, Harradine and team Field (Harradine
et al., 1998) concluded that the removal of third molars in an
A. According to the available space between the distal attempt to reduce the degree of late lower incisor crowding
surface of the second molar and the anterior border of the could not be justified.
ascending ramus of the mandible Research recommendations
• Class I: There is sufficient space to accommodate the Bishara and Andreasen recommendations: Bishara and An-
mesiodistal diameter of the crown of the third mo- dreasen (Bishara and Andreasen, 1983) suggest that if only
lar. the mandibular premolars are either missing or extracted,
• Class II: There is insufficient space to accommodate the lower third molar will, in the end, contact the upper 2nd
the entire mesiodistal dimension, i.e., part of the molar and prevent the over-eruption of the upper 3rd molar,
crown of the lower third molar is located within the hence, lower third molar extraction should be avoided in
ramus. these cases for ideal occlusion. Extraction of the third molar
should be avoided in cases with first and second molars of
• Class III: There is no space for the third molar to poor prognosis, particularly in non-growing persons with
erupt, i.e. the whole crown of the third molar is lo- Class II malocclusion or open-bite tendencies.
cated within the ramus.
National Institute of Dental Research in 1979 and the
B. According to the relative depth of the tooth within the American Association of Oral and Maxillofacial Surgery in
bony mandible 1993 recommendation: There is no evidence to suggest that
• Position A: The highest point of the tooth is at or a third molar is needed to develop the basal skeletal compo-
above the occlusal plane level of the adjacent tooth. nents of the maxilla and mandible. For cases involving dis-
talization, third molar extraction can be considered. There is
• Position B: The highest point of the tooth is below little rationale for extracting the lower third solely to avoid
the occlusal plane of the adjacent tooth but above future lower incisor crowding. If adequate room is available
the cervical margin of the adjacent tooth. for a third molar eruption, every effort should be made to
Position C: The highest point of the tooth is below the sec- bring these teeth into functional occlusion. If extraction of
third molars is indicated, it is preferable not to perform an
274 Third molar and its impaction

enculation (germectomy) procedure. crowding: Bergstrom and Jensen’s study (Bergstrom, 1960)
and Richardson and Mills (Richardson and Mills, 1990)
NICE guidelines for impacted third molar extraction are:
Studies refute the relationship between third molars impac-
• Prophylactic removal of pathology free impacted
tion and lower incisors crowding: Ades and Harradine (Ades
third molars should be avoided.
et al., 1990; Harradine et al., 1998)
• Extraction should only be undertaken if there is evi-
dence of pathology. The pathologies of those neces-
sities extraction are similar to those mentioned in
SIGN guidelines.
• Extraction can be undertaken if the patient has se-
vere peritonitis or has more than one minor inci-
dence of pericoronitis.
Exam night review

Prevalence of third molar impaction and hypodontia
• Third molars hypodontia are common among more
females; females to males ratio is 3:2 (Richardson,
1979).
• An incidence of 16.7% to 68.6%% has been reported
in the literature (Hashemipour et al., 2013; Bishara
and Andreasen, 1983).
Classification of third molar impaction
• According to the available space between the distal
surface of the second molar and the anterior border
of the ascending ramus of the mandible
• According to the relative depth of the tooth within
the bony mandible
• According to the inclination of the long axis of the
third molar about the long axis of the second molar
Treatment of impacted third molars
• Observation
• Operculectomy/surgical periodontics
• Coronotomy, Partial excision to avoid damage to the
inferior alveolar nerve (IAN)
• Surgical exposure
• Surgical reimplantation/transplantation
• Surgical removal/excision of tooth/teeth
• In selected cases with the co-operation of experi-
enced orthodontic opinion, active orthodontic ex-
trusion before surgical treatment might be consid-
ered to minimise IAN damage.
Lower incisor crowding and third molar debate
Studies relating third molars impaction to lower incisors
Third molar and its impaction 275

References
Ades AG, Joondeph DR, Little RM, et al. (1990) A long-term study
of the relationship of third molars to changes in the mandibular
dental arch. Am J Orthod Dentofacial Orthop 97: 323-335.
Bergstrom KJEOS. (1960) The significance of third molars in the
aetiology of crowding. 84-96.
Bishara SE and Andreasen G. (1983) Third molars: a review. Am J
Orthod 83: 131-137.
Harradine NW, Pearson MH and Toth B. (1998) The effect of ex-
traction of third molars on late lower incisor crowding: a random-
ized controlled trial. Br J Orthod 25: 117-122.
Hashemipour MA, Tahmasbi-Arashlow M and Fahimi-Hanzaei
F. (2013) Incidence of impacted mandibular and maxillary third
molars: a radiographic study in a Southeast Iran population. Med
Oral Patol Oral Cir Bucal 18: e140-145.
Richardson M and Mills K. (1990) Late lower arch crowding: the
effect of second molar extraction. Am J Orthod Dentofacial Orthop
98: 242-246.
Richardson ME. (1979) Late lower arch crowding facial growth or
forward drift? Eur J Orthod 1: 219-225.
Robinson PD. (1994) The impacted lower wisdom tooth: to remove
or to leave alone? Dent Update 21: 245-248.
276 Third molar and its impaction

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PLANETS OF

Dr. Mohammed Almuzian

Dr. Haris Khan

Dr. Ali Raza Jaffery

Dr. Farooq Ahmed

Dr. Samer Mheissen/ Specialist Orthodontist (Syria)

Orthodontic Indices............................................. 51 Maxillary suture fusion index..............................................67

Ideal characteristics of an index...........................................52 Mid-palatal suture density ratio (MSDR) ..........................67

Types of indices......................................................................52 Five stage midpalatal suture maturation method..............67

Other criteria of the DHC.....................................................56 EXAM NIGHT REVIEW.....................................................67

Aesthetic Component (AC)..................................................56 Orthodontic Anchorage....................................... 71

Indications of IPR..................................................................104 Orthodontics camouflage treatment modalities to treat

Methods of IPR .....................................................................104 Favourable features for orthodontics camouflage.............122

Air rotor stripping (ARS)......................................................105 Combined orthodontic-surgical approach.........................122

Exam night review.................................................................105 Aetiology of relapse of the treated Class II Division 1

Interproximal Enamel Reduction........................................105 malocclusion..........................................................................123

Class III Malocclusion.......................................... 133 The rationale for expansion treatment................................145

Classification of Class III malocclusion..............................134 Types of conventional RME..................................................146

severity ....................................................................................134 Proposed indications of the RME........................................146

Prevalence of Class III malocclusion...................................134 Contraindications and limitations of conventional

Aetiologies of Class III malocclusion..................................134 RME.........................................................................................147

Clinical features of Class III malocclusion.........................134 Potential complications of RME..........................................147

Interceptive treatment...........................................................135 Mid-palatal suture maturation classification .....................147

Growth Modification.............................................................136 Interpretation mid-palatal suture maturation classification:

High Angle Cases................................................. 169 Stability of AOB treatment...................................................186

Aetiology of high angle cases...............................................170 Causes of relapse of treated AOB cases...............................187

Clinical features of high angle cases....................................170 Retention of treated AOB cases............................................187

Radiographical features.........................................................170 Methods for retention...........................................................187

Treatment considerations.....................................................170 Posterior open bite.................................................................188

Exam night review.................................................................171 Causes of posterior open bite...............................................188

Anterior open bite................................................ 173 Treatment of posterior open bite.........................................188

Aetiology of AOB...................................................................174 Exam night review................................................................188

Classification of AOB............................................................174 Deep bite .............................................................. 199

Predictors of skeletal open bite............................................175 Aetiology deep overbite.........................................................200

Features of skeletal open bite................................................175 Principles of deep incisor overbite reduction.....................200

Aetiology of AOB...................................................................176 Consideration factors for the method of treating DOB....200

Digit Sucking Habit...............................................................178 These include:.........................................................................200

Hypodontia........................................................... 210 Supplemental supernumerary teeth....................................232

Classification of hypodontia ................................................211 Odontomes supernumerary ................................................232

Candidate genes ....................................................................211 ..................................................................................................

Impacted Canine.................................................. 247 Closed surgical exposure......................................................254

Prevalence and Incidence.....................................................248 Advantages of closed exposure............................................255

Development and eruption of maxillary canines..............248 Disadvantages of closed exposure.......................................255

Aetiology of impacted canines.............................................248 Crescini’s tunnel technique ..................................................255

Recent classification of aetiology of maxillary canine Choices of surgical exposure................................................255

impaction...............................................................................248 Mechanical eruption of the impacted canine.....................256

Theories of palatally impacted canines...............................249 permanent canine..................................................................256

Classification of impacted maxillary canines ...................249 Indication of transalveolar autotransplant.........................257

These include:.........................................................................249 Indication of surgical repositioning ...................................257

Investigations and diagnosis ...............................................250 Causes of poor outcome ......................................................257

Magnification technique.......................................................250 Impacted mandibular canine...............................................257

Parallax Technique.................................................................250 Exam Night Review...............................................................258

Third molar and its impaction............................. 273

2 Facial, Smile And Dental Analysis

Facial, Smile And Dental Analysis 3

4 Facial, Smile And Dental Analysis

Facial, Smile And Dental Analysis 5

6 Facial, Smile And Dental Analysis

Facial, Smile And Dental Analysis 7

8 Facial, Smile And Dental Analysis

Facial, Smile And Dental Analysis 9

10 Facial, Smile And Dental Analysis

Facial, Smile And Dental Analysis 11